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Pacific  Coast  Journal  of  Nursing 

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ORTHOPEDIC  SURGERY 
FOR  NURSES 


BY 

JOHN  McWILLIAMS  BERRY,  M.  D. 

// 

CLINICAL    PROFESSOR    OF    ORTHOPEDICS    AND    RONTGENOLOGY    AT    THE 
ALBANY   MEDICAL  COLLEGE,   NEW  YORK 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS  COMPANY 

1916 


GlFT  PACIFIC  COAST  JOURNAL 
OF    NURSING  TO  HYGEiNE  DEPT 


Copyright,  1916,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANY 
PHILADELPHIA 


15 


PREFACE  -ggg 


THE  chief  asset  of  a  trained  nurse  is  to  possess  a 
thorough  knowledge  of  the  principles  and  practice  of 
nursing ;  but,  in  addition,  she  should  understand  enough 
about  medical  and  surgical  subjects  to  make  her  own 
work  comprehensive  and  give  intelligent  advice  to  in- 
quiring friends  and  patients.  In  this  latter  connec- 
tion it  is  important  that  a  nurse  should  understand 
something  about  Orthopedic  Surgery. 

A  knowledge  of  how  to  recognize  orthopedic  de- 
formities at  an  early  stage;  the  danger  that  exists  in 
not  recognizing  them ;  the  possibilities  of  cure ;  and  the 
sad  results  of  lack  of  proper  treatment  would  be 
of  advantage  to  all  parents  and  individuals  interested 
in  children,  and  such  knowledge  should  be  expected 
of  all  trained  nurses. 

The  object  of  "Orthopedic  Surgery  for  Nurses"  is 
not  so  much  to  supply  nurses  with  a  text-book,  in  the 
sense  of  a  medical  student's  text-book,  as  to  give  them  a 
book  which  will  discuss  clearly  and  simply  the  recog- 
nition, diagnosis,  prognosis  and  treatment  of  the  more 
common  and  important  orthopedic  deformities.  In  or- 
der to  elucidate  and  emphasize  the  text  many  free-hand 
outline  illustrations  have  been  added. 

I  wish  to  express  my  thanks  to  Mrs.  Ralph  B.  Post, 
formerly  Supervising  Nurse  at  the  Albany  Hospital, 
for  her  criticism  of  the  work,  and  to  Dr.  William  P. 
Howard  for  the  free  hand  illustrations. 

.  -XT  Tr  JOHN  Me  WILLIAMS  BERBY. 

ALBANY,  N.  Y., 

June,  1916,  7 


743513 


CONTENTS 


PAGE 

INTRODUCTION    11 

CHAPTER   I 

CONGENITAL  ORTHOPEDIC  DEFORMITIES 12 

Club  Foot  (Talipes) 12 

Congenital  Dislocation  of  the  Hip 17 

Congenital  Wry-neck   (Torticollis) 21 

Asymmetry  of  Development 22 

CHAPTER  II 

ACQUIRED  DEFORMITIES  CAUSED  BY  DISEASE 24 

Rickets    (Rachitis) 

Infantile   Paralysis    (Anterior  Poliomyelitis) 29 

Birth  Palsy  (Spastic  Paralysis,  Little's  Disease) 31 

Tuberculosis   32 

Tuberculosis  of  the  Spine 34 

Tuberculosis  of  the  Hip 35 

Tuberculosis  of  the  Knee  and  Other  Joints 37 

Chronic  Deforming  Arthritis 41 

Senile  Osteo-arthritis 41 

Rheumatoid  Arthritis 42 

CHAPTER  III 

REGIONAL  DEFORMITIES 44 

The  Neck 44 

Acquired   Wry-neck 44 

Cervical    Rib. 44 

The  Chest 45 

Rachitic  Rosary 46 

Harrison's   Groove 46 

Pigeon-Breast 47 

Funnel-Chest 47 

The  Spine .47 

Kyphosis 48 

Lordosis 49 

Scoliosis 50 

Spondylitis  Deformans 53 

9 


10  CONTENTS 


PAGE 

The  Shoulder 54 

Congenital  Dislocation 54 

Obstetric  Paralysis 55 

Bursitis,  Subdeltoid 57 

The  Elbow 57 

Tennis  Elbow 57 

The  Wrist  and  Hand 57 

Congenital  Deformities 57 

Volkmann's  Ischemic  Paralysis 58 

Ganglion 59 

The  Fingers 59 

Congenital  Deformities 59 

Dupuytren's  Contracture 60 

Mallet  Finger .61 

Trigger  Finger 61 

CHAPTER  IV 
REGIONAL  DEFORMITIES   (CONTINUED) 62 

The  Pelvis 62 

Sacro-Iliac    Strain 62 

The    Hip '. .63 

The  Knee 63 

Genu    Valgum 64 

Genu   Varum G4 

Genu    Recurvatum 65 

Anterior  Bowing  of  the  Legs 65 

Housemaid's  Knee  (Prepatellar  Bursitis) 66 

Floating   Bodies 67 

Loose   Cartilages 67 

The  Foot 68 

Acquired  Club-Foot .68 

Pigeon-Toe 68 

The  Heel. 69 

Bursitis 69 

Exostosis  of  the  Os  Calcis ! . .  69 

The   Toes 70 

Congenital  Malformations 70 

Hallux  Valgus 71 

Hallux  Varus 72 

Hallux    Rigidus .72 

Hammer   Toe 73 

Trigger  Toe 74 

Anterior  Metatarsalgia  and  Morton's  Toe 74 

CHAPTER  V 
WEAK  FEET 76 

INDEX.,  87 


ORTHOPEDIC   SURGERY   FOR 
NURSES 

INTRODUCTION 

Modern  Orthopedic  Surgery  may  be  fairly  described 
as  the  surgery  of  the  deformities  and  disabilities  of  the 
apparatus  of  locomotion ;  the  phrase,  apparatus  of  loco- 
motion, being  used  in  a  broad  sense  to  include,  not  only 
the  lower  extremities,  but  also  the  trunk  and  upper  ex- 
tremities. Club  feet,  bow  legs,  curvature  of  the  spine, 
paralytic  deformities  of  the  arm,  etc.,  are  all  examples 
of  orthopedic  deformities.  Hare-lip,  cleft  palate,  her- 
nias, etc.,  are  deformities,  but,  since  they  have  nothing 
to  do  with  the  apparatus  of  locomotion,  they  would  not 
be  considered  as  within  the  province  of  Orthopedic 
Surgery. 

The  deformities  of  the  apparatus  of  locomotion  may 
be  divided  into  tAvo  main  classes:  congenital  and 
acquired.  Congenital  Deformities  are  present  at  birth 
and  can  be  recognized  at  that  time  or  become  apparent 
soon  after.  Their  causes  are  to  be  sought  for  in  the 
conditions  governing  intra-uterine  life.  Acquired  De- 
formities develop  after  birth  and  are  the  result  of 
diseases,  strain  and  overloading  of  the  body  framework, 
contractions,  etc. 

11 


CHAPTER  I 
ORTHOPEDIC  DEFORMITIES 


The  congenital  orthopedic  deformities  include :  club- 
bing of  the  extremities,  of  which  club  foot  is  the  most 
important;  congenital  dislocation  of  various  joints, 
especially  the  hip;  wry-neck;  asymmetrical  develop- 
ment ;  missing  bones,  supernumerary  bones,  malformed 
or  misplaced  bones,  etc. 

CLUB  FOOT— TALIPES 

Club  Foot  or  Talipes,  which  is  the  correct  medical 
term,  is  a  deformity  in  which  there  is  an  abnormality 
in  the  anatomical  relation  of  the  foot  to  the  leg  or  of 
one  part  of  the  foot  to  another  part.  It  has  been  ob- 
served that  club  foot  sometimes  runs  in  families,  being- 
transmitted  through  the  male  side.  The  deformity  can 
take  place  in  any  direction  that  the  foot  can  move. 
Thus  there  may  be : 

Deformity  (the  foot  turned)  downward — talipes 
equinus  (Fig.  1). 

Deformity  (the  foot  turned)  upward — talipes  cal- 
caneus  (Fig.  2). 

Deformity  (the  foot  turned)  inward — talipes  varus 
(Fig.  3). 

12 


CLUB   FOOT TALIPES 


13 


Fig.    1. 
Talipes  equinus. 


Fig.    2. 
Talipes    calcaneus. 


Fig.    3. 
Talipes  varus. 


Fig.   4. 
Talipes  valgus. 


14  ORTHOPEDIC  SURGERY  FOR  NURSES 

Deformity  (the  foot  turned  outward) — talipes  val- 
gus  (Fig.  4). 

Combinations  of  deformities  may  be  present,  in  fact 
they  usually  are.  The  most  common  form,  and  the  one 
usually  referred  to  by  the  term  club  foot,  is  a  com- 
bination of  downward  and  inward  deformity  or,  to 
designate  it  by  the  correct  medical  term,  Talipes 
Equino-Varus  (Fig.  5). 


Fig.    5. 
Club  Foot — Talipes  equino-varus. 

Congenital  club  foot  is  usually  easily  recognized. 
In  a  new-born  baby  suffering  from  equino-varus  the 
foot  is  turned  downward  and  inward,  and  is  rotated  so 
that  the  sole  of  the  foot  faces  inward  or,  in  extreme 
cases,  almost  upward  (Fig.  5).  Sometimes  a  new- 


lilt  PAUMU 

OF  NU 

CLUB    FOOT TALIPES  15 

born  baby  holds  its  feet  in  a  position  which  gives  the 
impression  of  deformity,  but,  if  its  feet  can  be  easily 
turned  into  a  normal  position,  no  club  foot  is  present. 
A  simple  test  in  some  of  these  doubtful  cases  is  to  warm 
the  infant  thoroughly  by  placing  it  near  a  fire;  if  the 
child  has  no  deformity  it  will  flex  the  thighs  on  the 
abdomen,  the  legs  on  the  thighs,  and  turn  the  feet  out- 
ward. 

The  symptoms  of  club  foot  are  those  of  a  progressing 
deformity,  making  walking  more  and  more  difficult. 
The  soft  tissues,  such  as  ligaments  and  fasciae,  become 
contracted  and  the  bones  gradually  become  distorted. 
The  foot  is  turned  more  and  more  into  a  deformed  posi- 
tion until  walking  becomes  almost  impossible.  In  the 
more  common  form  of  club  foot  (equino-varus),  in 
addition  to  the  turning  of  the  foot,  there  may  be  a 
rotation  in  of  the  whole  leg,  causing  an  exaggerated 
pigeon  toe  walk,  one  foot  having  to  be  lifted  over  the 
other  (Fig.  6).  The  normal  development  of  the  foot 
and  leg  is  interfered  with  and,  in  unilateral  cases,  the 
affected  extremity  is  noticeably  the  smaller.  There  is 
no  pain  except  for  the  pain  associated  with  corns  and 
callosities,  which  develop  on  the  feet  as  the  result  of 
their  peculiar  position. 

The  treatment  of  club  foot  should  begin  almost  as 
soon  as  the  child  is  born  and  should  be  continued  until 
the  deformity  is  overcorrected  and  there  is  no  tendency 
to  recurrence.  This  usually  means  a  long  period  of 
treatment  and  supervision,  because  the  deformity  is  very 
resistant  to  treatment  and  has  a  marked  tendency  to 


16 


ORTHOPEDIC  SURGERY  FOR  NURSES 


recur.  Half  cures  are  no  cures  at  all.  Many  cases  seem 
to  be  cured  for  a  time,  but,  owing  to  a  want  of  care 
or  to  negligence  a  relapse  takes  place.  The  possibility 
of  a  relapse  exists  so  long  as  growth  is  going  on;  writh 
the  strength  and  stability  of  the  tissues,  which  follows 
the  attainment  of  full  growth,  the  danger  of  increase 
or  recurrence  of  deformity  disappears.  This  is  true  of 
many  deformities  other  than  club  feet. 

The  longer  a  case  goes 
|  without  treatment  the 
^  more  difficult  is  its 
cure ;  therefore,  the 
prime  essential  of  suc- 
c  e  s  s  f  ul  treatment  is 
early  recognition  of  the 
deformity.  In  very 
mild  cases  all  that  may 
be  required  is  corrective 
manipulation  by  the 
nurse  or  parent  several 
times  a  day.  In  more 
severe  cases  adhesive 
strapping  or  a  light 
plaster-of -Paris  cast 
may  be  required  to 
hold  the  foot  in  a  correct  position  after  the  manipula- 
tion. Resistant  cases  and  cases  seen  at  a  later  date, 
when  the  deformity  has  become  more  fixed,  require 
manipulative  correction  under  an  anesthetic.  This 
correction  may  be  with  or  without  subcutaneous  cutting 


Neglected    club    foot    (After    Whitman). 


CONGENITAL  DISLOCATION   OF   THE   HIP  l 

of  contracted  tendons  and  fasciae,  and  is  followed  by 
retention  in  a  plaster-of-Paris  dressing.  Neglected 
cases  require  severe  operative  measures  on  the  con- 
tracted tissues  and  deformed  bones,  and  a  perfectly 
formed  foot  can  never  be  obtained. 

CONGENITAL  DISLOCATION  OF  THE  HIP 

Congenital  Dislocation  of  the  Hip  is  a  deformity  in 
which  the  head  of  the  femur  is  partially  or  completely 
displaced  from  its  socket  (the  acetabulum)  (Fig.  7). 
It  may  be  present  on  one  or  both  sides  of  the  body,  and 
occurs  more  frequently  in  girls  than  in  boys.  It  is  not 
a  very  common  deformity,  but  it  is  common  enough  to 
cause  very  unfortunate  mistakes  in  diagnosis  at  times. 

The  deformity  may  not  be  recognized  at  birth  and 
only  becomes  apparent  when  the  child  tries  to  walk. 
Children  with  congenital  dislocation  of  the  hip  or  hips 
do  not  walk  as  early  as  most  children ;  there  is  usually 
a  prominence  of  the  affected  hip  or  hips  backward, 
and  when  the  child  does  walk,  the  gait  is  abnormal. 

Symptoms. — As  has  been  said,  the  symptoms  may  not 
show  themselves  until  the  child  begins  to  walk.  If  the 
dislocation  is  only  on  one  side,  the  leg  on  that  side  is 
shorter  (Fig.  8),  and  the  child  walks  with  a  marked 
limp.  If,  however,  the  dislocation  is  present  on  both 
sides,  the  child  walks  with  a  characteristic  aduck  like" 
waddle.  The  hips  are  very  prominent  behind  and  there 
is  a  marked  bending  forward  of  the  lower  spine  (lor- 
dosis)  (Fig.  9).  The  child  tires  easily  and  may 
complain  of  pain  in  the  hips. 


18 


ORTHOPEDIC  SUBGEEY  FOR  NUESES 


The  course  of  untreated  congenital  dislocation  of  the 
hip  is  a  progressive  deformity  and  weakness,  which 
in  time  may  make  walking  almost  impossible. 

Treatment — There  are  two  well-known  methods  of 


Fig.    7. 

Tracing  of  an  X-Ray  picture   of  congenital   dislocation   of  the   hip. 
(A)    is   the   normal   hip.      (B)    is   the   dislocated   hip. 

treatment  in  congenital  dislocation  of  the  hip:  one  is 
known  as  the  open  method  and  the  other  as  the  bloodless 
method.  The  latter  was  made  famous  by  Dr.  Lorenz 
of  Vienna,  and  is  generally  known  as  the  Lorenz 
method.  In  the  open  or  operative  method,  the  hip  joint 


CONGENITAL  DISLOCATION    OF    THE    HIP 


19 


is  opened,  the  acetabuhim  is  scraped  out  and  the  head 
of  the  femur  is  put  in  place.  This  method  is  more  or 
less  dangerous  and  is  not  generally  used.  In  the  Lorenz 


Fig.    8. 

Characteristic     at- 
titude   and    shorten- 

si ,  •?.'£;«:: 

location  of  the  hip 
(Left).  In  the  draw- 
ing it  looks  as  if 
the  right  leg  was 
the  shorter  of  the 
two,  hut  this  is  due 
to  the  fact  that  the 
pelvis  is  tilted. 


Fig.    10. 

Plaster-of-Paris  cast — 
Frog  position — Unilateral 
congenital  dislocation  of 
the  hip. 


method,  the  displaced  head  of  the  femur  is  manipulated 
back  into  place  and  held  in  position  by  a  plaster  cast 
until  it  has  worn  a  more  perfect  socket  for  itself.  The 


20 


ORTHOPEDIC   SURGERY  TOR  NURSES 


position  in  which  the  leg  is  placed  to  accomplish  this 
is  known  as  the  "Frog  Position77  (Figs.  10,  11).  It 
usually  takes  one  or  more  years  to  cure  a  case  of  con- 


rig.  11. 


Plaster-of-Paris    cast — Frog    position — Double    congenital 
dislocation  of  the   hip    (After   Whitman). 


genital  dislocation  of  the  hip  and,  if  the  treatment  is 
not  started  early  enough,  a  cure  is  impossible.  It  is 
very  difficult  or  impossible  to  cure  congenital  disloca- 
tion of  the  hip  in  a  child  more  than  eight  years  old. 


CONGENITAL    WRY-NECK TORTICOLLIS 


21 


CONGENITAL  WRY-NECK—TORTICOLLIS 
In   Congenital    Wry-Neck   or   Torticollis,  the   child 
is  born  with  the  head  held  to  one  side,  rotated  somewhat 
to  the  opposite  side  and  tilted  back   (Fig.   12).     The 


Fig.    12. 
Wry-Neck,   left  sided. 


position  is  due  to  a  contraction  of  the  sterno-cleido 
mastoid  muscle,  the  exact  cause  of  which  is  in  dispute. 
In  mild  cases  and  in  cases  recognized  early  correc- 
tive manipulation  may  be  sufficient  to  effect  a  cure ;  but, 
in  resistant  and  neglected  cases  it  is  necessary  to  divide 
the  tendon  of  the  muscle,  overcorrect  the  deformity 
and  put  on  a  plaster-of-Paris  dressing,  including  the 
head  and  chest  (Fig.  13).  Close  supervision  is  neces- 


22 


ORTHOPEDIC   SURGERY   FOR   NURSES 


sary  for  a  long  time  to  see  that  recurrence  does  not  take 
place. 

ASYMMETRY   OF   DEVELOPMENT 

Comparatively   few   individuals   are   born   perfectly 
formed;  one  leg  may  be  a  little  longer  than  the  other, 


Fig.    13. 
Wry-Neck   overcorrected    and    in    Cast. 

one  arm  a  little  larger  than  the  other,  etc.  Sometimes 
the  asymmetry  affects  one  whole  side  of  the  body,  so 
that  the  individual  seems  to  be  a  combination  of  two 
bodies  of  unequal  size  (Fig.  14).  Individuals  with 
asymmetrical  development  are  usually  perfectly  well 


ASYMMETRY    OF    DEVELOPMENT 


and  suffer  no  inconvenience  other  than  possibly  strains 
from  the  unequal  length  of  the  limbs,  which  in  some 
cases  may  cause  a  curvature  of  the  spine. 

Missing  Bones  and  Supernumerary 
Bones  or  Abnormally  Placed  or  Formed 
Bones  are  frequently  the  cause  of  char- 
acteristic deformities.  The  deformities 
are  usually  easily  recognized,  but  it  is 
not  always  possible  to  cure  them. 

There  are  many  congenital  orthopedic 
deformities  other  than  those  here  dis- 
cussed, but  it  is  not  necessary  that  a 
trained  nurse  should  know  all  of  the  con- 
genital deformities  or  very  much  about 
any  of  them.  She  should  understand, 
however,  that  there  are  such  deformities, 
that  they  are  sometimes  difficult  to  recog- 
nize, and  that,  if  they  are  not  recognized 
early,  they  may  become  incurable.  She 
should,  therefore,  appreciate  the  fact  that, 
any  abnormality  in  a  child  sliould  not  be 
overlooked  or  neglected.  For  example,  a 
child  who  constantly  holds  its  feet  in 
a  peculiar  position,  who  walks  with  a 
limp  or  holds  the  head  on  one  side,  may  be  suffering 
from  club  feet,  congenital  dislocation  of  the  hip  or 
wry-neck  as  the  case  may  be.  Such  cases  should 
always  be  investigated  and  never  passed  over  with  the 
remark  so  frequently  made  :  "he  (or  she)  will  probably 
outgrow  it." 


u  n  i  i  a  t  e  r  a  i 
1  de- 


CHAPTEE  II 
ACQUIRED  DEFORMITIES  CAUSED  BY  DISEASE 

The  diseases  which  commonly  cause  orthopedic  de- 
formities are:  rickets,  infantile  paralysis,  birth  palsy, 
tuberculosis,  chronic  deforming  arthritis,  etc. 

RICKETS 

Rickets  or  Rachitis  is  a  constitutional  disorder 
which  occurs  chiefly  in  children,  is  associated  with 
malnutrition  and  manifests  itself  largely  by  changes 
in  the  bones. 

Causes — The  chief  contributing  causes  of  rickets 
are  supposed  to  be  improper  food  and  lack  of  sunlight 
and  fresh  air.  The  disease  is  very  common  in  the 
poorer  class  of  Italian  children  who  are  brought  up 
largely  on  cereals.  It  is  also  common  among  negro 
children,  but  is  not,  however,  confined  to  the  children 
of  the  poor,  since  improper  feeding  may  occur  among 
all  classes.  For  example,  a  marked  case  of  rickets 
developed  in  the  child  of  well-to-do  people  because, 
in  the  effort  to  bring  the  baby  up  in  a  perfectly  healthy 
way,  all  the  milk  that  the  baby  took  was  boiled.  The 
child's  mother  was  under  the  impression  that  the  baby 
should  be  fed  only  on  sterilized  milk  and  that  boiling 
was  the  way  to  sterilize  it. 

24 


RICKETS 


25 


Foods  containing  an  excess  of  starch  and  too  little 
fat  are  supposed  to  be  conducive  to  rickets.  Babies 
brought  up  on  condensed  milk  are  apt  to  be  rickety,  as 
are  also  the  babies  brought  up  on  proprietary  foods. 
Cereals,  boiled  milk,  condensed  milk 
and  proprietary  foods  do  not  always 
contain  the  proper  ingredients  for  per- 
fect growth,  despite  the  fact  that  some 
children  thrive  on  them.  The  whole 
subject  of  infant  feeding  is  a  most  im- 
portant one  and  is  too  often  neg- 
lected. Further  discussion  of  the  sub- 
ject is  not  within  the  province  of  this 
work,  but  it  may  be  well,  at  this  time, 
to  impress  upon  the  trained  nurse  its 
important  bearing  on  the  future  wel- 
fare of  babies. 

In  all  cases  of  rickets  there  is  an 
abnormal  growth  of  bone.  Bones  are 
at  first  composed  entirely  of  cartilage, 
and  become  hard  and  firm  by  the  de- 
position of  lime  salts.  This  process 
takes  place  principally  at  the  growing 
ends  (the  epiphyses)  and  beneath  the 
periosteum,  and  is  known  as  ossifica- 
tion. In  rickets  the  normal  process  is 
interfered  with,  and  the  ossification  is  irregular  or  par- 
tially absent ;  one  of  the  results  of  this  is  an  abnormal 
softness  of  the  bones. 

Symptoms. — The  symptoms  of  rickets  are  as  follows : 


Fig.    15. 

Rickets. — En- 
larged abdomen 
and  1  o  r  d  o  s  i  s 
(Bradford  and 
Lovett). 


26 


ORTHOPEDIC  SURGERY  FOR  NURSES 


There  is  a  profuse  sweating  of  the  head.  The  anterior 
fontanelle  remains  open  (it  should*  close  at  eighteen 
months).  The  forehead  is  prominent  and  square.  The 
abdomen  is  enlarged,  due  in  part  to  an  enlargement 
of  the  liver,  and  when  the  child  stands  there  is  a 


Fig.    16. 

General  Rickets. — Note  the  beading  of  the  ribs  (rickety 
rosary) — the  enlarged  abdomen — the  enlarged  epiphyses  at 
the  wrist  and  ankle — the  bowing  of  the  legs. 

marked  forward  hending  (lordosis)  of  the  spine  (Fig. 
15).  The  growing  ends  of  the  bones  (the  epiphyses) 
are  enlarged ;  this  is  noticeable  especially  at  the  wrists 
and  ankles.  The  ribs  are  beaded  (rickety  rosary). 


RICKETS 


27 


The  long  bones  are  bowed  (Fig.  16).  There  is  delayed 
dentition  and  the  child  does  not  walk  as  early  as  it 
should.  The  spine  may  be  weak  and  the  child  is  unable 
to  sit  up  straight  (Fig.  17).  A  normal  baby  should 
hold  its  head  up  and  begin  to  use  its  hands  at  three 


Fig.    17. 
Spinal     rickets. — Kyphosis. 


Fi§r.   18. 

Postural    deformity    in 
spinal    rickets. 


months,  sit  up  at  six  months,  creep  at  eight  months, 
walk  and  say  a  few  words  at  fourteen  months.  If  a 
child  cannot  do  these  things,  or  if  dentition  is  delayed, 
look  for  symptoms  of  rickets. 

The  abnormal  softness  of  the  bones  leads  to  various 


ORTHOPEDIC  SURGERY  FOR   NURSES 


deformities,  the  most  pronounced  of  which  are  in 
the  chest  and  legs.  These  will  be  discussed  under  re- 
gional deformities. 

Treatment. — The  essential  treatment  in  the  active 
stage  of  the  disease  is  proper  feeding,  sunlight  and  fresh 

air.  Rest  and  a  tonic  treat- 
ment are  also  usually  indi- 
cated. If  the  spine  is  weak 
the  child  should  be  placed  on 
a  firm  mattress,  otherwise  the 
weight  of  the  body  tends  to 
cause  curvature  (Fig.  18). 
Sometimes  the  weight  of  the 
limbs  hanging  over  the  arm 
of  the  nurse,  if  the  child  is 
carried  a  great  deal,  causes 
them  to  bow  forward;  at 
other  times  the  way  in  which 
the  child  sits  tends  to  cause 
bowing  (Fig.  19).  Older 
children  with  acute  rickets 
should  not  be  urged  to  stand 
and  walk,  since  this  will  tend 
to  increase  the  deformity  of  the  legs. 

The  disease  is  usually  self  limiting  and  quiets  down 
in  a  few  months  or  years,  at  which  time,  if  the  resulting 
deformities  are  pronounced,  they  can  be  corrected  by 
operation. 


Fig.    19. 

Postural    deformity    in 
rickets,    bow    legs. 


INFANTILE  PARALYSIS 

INFANTILE  PARALYSIS 

Infantile  paralysis  or  anterior  poliomyelitis  is  an 
infectious  epidemic  disease  which  chiefly  affects  chil- 
dren. Only  comparatively  recently  it  has  been  dis- 
covered that  the  disease  is  caused  by  a  germ.  The  germ 
excites  an  acute  inflammation  of  the  spinal  cord,  des- 
troying or  injuring  nerve  cells,  and  thereby  causing  a 
paralysis  of  the  muscles  controlled  by  these  cells. 

Symptoms — The  initial  symptoms  are  those  of  an 
acute  fever  and  may  be  very  mild,  the  child  simply 
complaining  of  not  feeling  well  or  perhaps  has  a  head- 
ache on  going  to  bed.  In  the  morning  the  child  may  be 
found  paralyzed.  On  the  other  hand,  the  symptoms  may 
be  much  more  severe  and  the  child  be  ill  for  several 
days  with  a  high  fever  and  convulsions. 

The  paralysis  which  occurs  is  of  the  flaccid  type,  i.  e., 
the  affected  parts  hang  limp  and  lifeless.  The  original 
paralysis  usually  clears  up  to  a  considerable  extent: 
for  example,  both  legs  and  both  arms  may  be  affected 
at  first  and  later  recovery  may  take  place  except  in  one 
leg.  The  child  is  almost  always  left  with  a  certain 
amount  of  paralysis  which,  unless  properly  treated, 
becomes  more  and  more  deforming.  This  is  due  to  the 
fact  that  contractures  take  place. 

Contractures  occur  from  the  following  reasons :  Nor- 
mally the  muscles  are  in  a  condition  of  tone,  i.  e., 
slightly  contracted.  They  are  also  arranged  in  sets 
opposed  to  each  other.  For  example,  one  set  of  muscles 
flexes  the  forearm  upon  the  arm,  and  this  set  of  muscles 


30 


ORTHOPEDIC   SURGERY  FOR   NURSES 


is  opposed  by  another  set  which  extends  the  forearm. 
Now,  if  one  set  of  muscles  is  paralyzed  and  not  the 
other,  it  can  be  readily  understood  how  the  pull  of  the 
active  muscles  would  cause  contrac- 
tion and  deformity.  Sometimes 
horrible  deformities  may  result  and 
the  child  be  unable  to  walk  at  all, 
or  at  best  walk  like  an  animal, 
on  all  fours. 

There  is  always  marked  atrophy 
of  the  paralyzed  part  (Fig.  20), 
and  it  is  cold  and  lifeless  to  the 
touch. 

Treatment. — The  treatment  of  the 
acute  stage  is  not  the  province  of 
orthopedic  surgery.  Orthopedic 
surgery  is  concerned  only  with  the 
resulting  deformities.  Electricity, 
massage,  muscle  training,  and  the 
use  of  braces  are  all  important  aids 
in  combating  deformity  and  in 
building  up  weakened  muscles. 
After  deformities  have  occurred, 
surgical  measures,  such  as  forcible 

Infantile        Paralysis. 

(Anterior    poliomyelitis   manipulation,    tendon    cutting    (te- 

of    right    leg)     (Bradford 

notomy),  muscle  transference,  the 
insertion  of  artificial  silk  ligaments,  nerve  anastomoses, 
etc.,  are  required.  After  the  correction  of  the  deformity 
the  correction  must  be  held  by  the  use  of  braces,  muscle 
training,  etc.  The  treatment  is  usually  long  and  re- 


Fig.  20 


BIRTH    PALSY 


31 


quires  much  patience,  but  it  is  oftentimes  surprising 
how  much  can  be  done  to  relieve  what  would  otherwise 
be  a  most  distressing  condition. 

BIRTH  PALSY 

Birth  Palsy,  Spastic  Paralysis  or  Little  s  Disease,  as 
it  is  variously  known,   is  a  disease  characterized  by 


Fig.    21. 
Spastic  Paralysis   (Little's  disease).     Characteristic  attitude   (Whitman). 

muscle  weakness  and  inco-ordination  by  muscle  stiffness 
(spasm)  and  loss  of  control. 


32  ORTHOPEDIC  SURGERY  FOR  NURSES 

Causes — The  cause  of  the  disease  is  supposed  to  be 
an  injury  to  the  higher  nerve  centers.  It  is  often  due 
to  an  injury  to  the  brain  of  the  child  in  cases  of  severe 
labor  where  forceps  are  used;  hence  the  term  birtli 
palsy. 

Symptoms — The  disease  is  usually  ushered  in  with 
convulsions  followed  by  paralysis  of  the  spastic  type. 
This  is  a  type  of  paralysis  different  from  infantile 
paralysis.  In  the  latter  disease  the  affected  limbs 
are  limp  and  "hang  dead/'  in  birth  palsy  the  affected 
limbs  are  held  stiffly,  and  are  spastic  (Fig.  21).  The 
muscles  are  not  actually  paralyzed;  they  can  contract, 
but  there  is  a  loss  of  co-ordination,  a  loss  of  control 
over  them.  The  intellect  is  very  apt  to  be  affected 
in  cases  of  spastic  paralysis,  the  child  being  more 
or  less  feeble  minded.  There  are  also  present  peculiar 
movements  of  the  hands  and  arms  known  as  athetoid 
movements.  Atrophy  of  the  affected  limbs  is  not  so 
marked  as  in  infantile  paralysis. 

The  course  of  the  disease  is  progressively  deforming, 
and  contractures  occur  as  in  infantile  paralysis. 

Treatment. — In  the  treatment  of  the  later  stages, 
after  deformity  has  occurred,  practically  the  same  prin- 
ciples apply  as  in  the  treatment  of  infantile  paralysis. 

TUBERCULOSIS 

Tuberculosis  is  an  infectious  disease,  which,  when 
it  affects  the  bones  and  joints,  causes  destruction  of 
tissues  with  deformity.  The  cause  of  the  disease  is  the 
tubercle  bacillus. 


TUBERCULOSIS 


33 


Symptoms. — The  symptoms  vary  with  the  location 
of  the  disease,  hut  there  are  certain  general  symptoms 
that  are  always  present  and  common  to  any  localizing 
focus.  These  are : 

Pain. 

Tenderness. 

Stiffness  (muscle  spasm). 

Deformity. 


Fig.    22. 

Tuberculosis  of  the  cervical  spine   (Pott's  disease).     Characteristic 
attitude  to  avoid  jarring-  of  the  diseased  vertebrae   (After  Whitman). 

Also  there  is  a  "falling  off"  in  the  general  health  of 
the  patient.     The  patient  tires  easily,  is  irritable,  and 


ORTHOPEDIC  SURGERY  FOR  NURSES 


in  children  there  is  a  restlessness  during  sleep  and 
unight  cries.'7  The  night  cries  are  due  to  the  fact  that 
in  sleep  the  muscles,  which  by  their  contraction  during 
the  day  kept  the  diseased  parts  protected,  are  now  re- 
laxed and  any  movement  causes  pain. 

The  symptoms  of  the  disease  when  localized  in  the 
most  usual  situations  are  as  follows: 


Fig.    23. 

Tuberculosis  of  the   dorsal   spine    (Pott's  disease).      Characteristic 
attitude.      Showing   rigidity   of  the  spine    (After  Whitman). 

In  the  spine  (Pott's  Disease)  : 

Pain. — The  patient  complains  of  pain  in  the  hack 
or  in  the  abdomen.  Whenever  a  child  complains 
of  continued  pain  in  the  abdomen,  for  which  no 
other  cause  can  be  found,  the  spine  should  always 
be  examined  for  beginning  tuberculosis. 


TUBERCULOSIS 


35 


Tenderness. — The  spine  is  sensitive  to  jarring  of  any 
kind  (Fig.  22).  Running  or  rough  riding  may  be 
painful. 

Stiffness. — On  account  of  the  above  the  spine  is  held 
stiffly  by  muscle  spasm  and  is  not  bent.  Thus  in 

picking  up  objects 
from  the  floor  the  back 
is  held  rigid  and  all 
bending  is  made  at  the 
hips  and  knees  (Figs. 
23,  24). 

Deformity. — In  the  later 
stages  of  tuberculosis 
of  the  spine  a  knuckle 
of  bone  appears  on  the 
back  over  the  seat  of 
the  trouble.  This  is 
due  to  the  diseased 
bone  crumpling  up  and 
forcing  the  spinous 
processes  of  the  ver- 
tebrae backward  (Figs. 
25,  26). 
In  the  hip : 

Pain. — The  patient  complains  of  pain  in  the  hip  or 
in  the  knee.  When  a  child  complains  of  pain  in 
the  knee,  and  no  cause  is  evident,  the  hip  should 
be  examined  for  beginning  tuberculosis. 
Tenderness. — The  hip  is  sensitive  to  jarring  and 
motions  of  all  kinds. 


Fig.    24. 

Tuberculosis  of  the  dorsal  spine 
(Pott's  disease).  Characteristic 
attitude  to  avoid  jarring  of  the 
spine. 


36 


OETHOPEDIC  SURGERY  FOR   NURSES 


Stiffness. — The  stiffness  of  muscles  around  the  hip 
(muscle  spasm) ,  causes  the  hip  to  be  held  more  or 
less  rigid.  It  is  usually  held  in  such  a  position 
that  the  leg  on  that  side  seems  longer  or  shorter 


! 


Fig.    25. 
Deformity     (kyphosis)    in    tuberculosis    of    the    spine    (After    Whitman). 

than  the  opposite  one,  although  the  actual  length 
of  the  two  legs  may  be  the  same  Fig.  27). 
The  result  is  that  the  child  walks  with  a  limp. 
Deformity. — In  the  later  stages,  due  to  contractions 
and  bony  destruction,  the  leg  may  become  de- 
formed and  flexed  on  the  thigh  (Fig.  28). 


TUBERCULOSIS 


In  the  knee  and  other  joints,  (Fig.  29)  the  symptoms 


are: 


Fig.    26. 

Sagittal  section  of  kyphosis  in  tu- 
berculosis of  the  spine  (Pott's  dis- 
ease). 


Fig.    27. 

Tuberculosis  of  the 
hip.  Characteristic 
attitude  in  the  early 
stage  of  tuberculosis 
of  the  right  hip. 
The  pelvis  is  tilted 
in  such  a  way  that 
the  right  leg  appears 
to  be  longer  than 
the  left. 


Pain. 

Tenderness. 

Stiffness    (muscle  spasm). 

Deformity  swellings  and  contractions, 


38 


ORTHOPEDIC  SURGERY  FOR   NURSES 


Fig.    28. 

Tuberculosis  of 
the  hip.  Charac- 
teristic attitude 
in  ad  v  a  need 
stage  of  tuber- 
culosis of  the 
left  hip.  The  left 
leg  is  shortened 
and  atrophied, 
and  the  thigh  is 
flexed  onto  the 
abdomen  so  that 
in  order  to  bring 
the  foot  to  the 
ground  the  spine 
has  to  bend  for- 
ward (lordosis) 
(After  Whitman). 


The  course  of  tuberculous  disease  in 
all  cases,  unless  properly  treated,  is 
progressively  worse,  with  the  production 
of  very  severe  deformities.  The  de- 
formities are  due  to  two  causes:  first, 
contraction  and  second,  the  actual 
destruction  of  tissue.  The  later  stages 
of  tuberculous  disease  are  frequently 
complicated  by  abscess  formation,  the 
usual  result  being  that  the  abscess  rup- 
tures and  forms  a  persistent  discharging 
sinus  or  "running  sore." 

In  recognizing  tuberculosis  any  pains 
in  the  bones  or  joints  of  a  child  should 
not  be  neglected  or  attributed  to  ff grow- 
ing pains/'  The  common  story  in  many 
cases  of  tuberculosis  is  something  like 
this :  The  mother  asks :  "Do  you  think 
Willie  walks  with  a  limp  ?  He  does  not 
look  well  to  me;  he  seems  all  right  in 
the  morning  but  he  tires  so  easily  and 
sometimes  toward  night  it  seems  to  me 
that  he  walks  with  a  limp.  Sometimes 
he  says  his  hip  hurts  him  and  sometimes 
he  complains  of  his  knee.  He  is  restless 
at  night  and  wakes  up  crying  and  says 
his  knee  hurts.  I  have  looked  at  his 
knee  and  it  looks  all  right.  His  father 
thinks  it  is  nothing  but  rheumatism  or 
growing  pains.  I  have  thought  of  tak- 


TUBERCULOSIS 


39 


ing  him  to  the  doctor  but  maybe  that  would  be  foolish. 
Do  you  think  it  is  growing  pains  ?"     This  would  be  the 


Fi*.    29. 

Tuberculosis    of    the    knee.      Characteristic    appearance. 
(Bradford   and   Lovett). 

time,  if  ever,  for  a  trained  nurse  to  show 
her  knowledge.  Probably  the  boy  has 
beginning  tuberculosis  of  the  hip,  and,  if 
a  diagnosis  can  be  made  and  proper  treat- 
ment started,  the  trouble  may  be  checked 
before  serious  damage  has  taken  place. 

Treatment. — The  three  great  essentials 
in  the  treatment  of  tuberculosis  are  rest, 
fresh  air  and  good  food,  but  nature  must 
cure  the  disease.  Rest  is  obtained  for 
children  by  placing  them  on  a  gas  pipe 
frame  covered  with  canvass  (Bradford 
frame,  Whitman  frame,  etc.)  (Figs.  30, 
31,  32).  The  use  of  plaster-of-Paris 
casts  and  braces  is  another  way  of  em- 
ploying rest  treatment,  since  they  hold 
the  diseased  parts  and  prevent  motion 
(Figs.  33,  34,  35,  36).  When  the  dis- 
ease is  clearly  localized  in  a  bone  or 


Fig:.   30. 

Bradford 
frame.  A  gas 
pipe  frame 
covered  with 
canvas. 


40 


ORTHOPEDIC  SURGERY  FOR  NURSES 


Fig.    31. 
Patient  on  a  Bradford  frame. 


Fig.    32. 
Patient  on  a  Whitman  frame. 


Fig.   33. 

P 1  a  s  t  e  r-of- Paris 
cast  applied  for  tu- 
berculosis of  the 
spine. 


Fig.    34. 

Plaster-of-Paris  cast  applied  for 
tuberculosis  of  the  hip. 


CHRONIC    DEFORMING    ARTHRITIS  41 

joint  it  may  be  possible  to  operate  and  remove  the 
affected  area.  After  the  disease  has  healed  and  left 
deformities  they  may  be  corrected  or  improved  by 
operative  treatment.  The  treatment  of  tuberculosis  is 
usually  a  slow  and  tedious  process,  and  must  be  per-* 
sisted  in  to  effect  a  cure. 

CHRONIC  DEFORMING  ARTHRITIS 

The  name  describes  the  disease ;  a  chronic  disease  of 
the  joints  deforming  them.  There  are  two  forms  of 
chronic  deforming  arthritis,  commonly  known  as  senile 
osteo-arthritis  and  rheumatoid  arthritis. 

Senile  osteo-arthritis  is  very  common ;  probably  there 
are  very  few  people  over  sixty  years  of  age  who  do  not 
show  evidence  of  the  disease  in  more  or  less  degree. 
The  most  common  situation  of  the  disease  is  in  the 
fingers,  where  it  manifests  itself  in  knobby  swellings 
about  the  joints.  These  nodules  are  small  bony  out- 
growths and  are  known  as  Heberden's  nodes.  They  are 
slightly  painful  and  tender,  and  cause  stiffness  of  the 
fingers.  No  constitutional  symptoms  characterize  the 
disease. 

The  next  most  common  situation  of  the  disease  is  in 
the  knee  joints.  The  attention  of  the  patient  is  usually 
first  called  to  the  trouble  by  a  grating  sound  on  moving 
the  knee.  Pain  and  stiffness  in  the  knee  may  become 
very  pronounced  and  the  patient  suffers  severely.  The 
disease  may  attack  the  hip,  the  spine,  or  in  fact  any 
joint  of  the  body. 


42 


ORTHOPEDIC  SURGERY  FOR   CURSES 


The  treatment  of  senile  osteo-arthritis  is  verv  un- 
satisfactory. 

Rheumatoid  Arthritis  attacks  younger  subjects,  and 
oftentimes  an  infection  seems  to  be  at  the  bottom  of  the 


Fig.    35. 

Rear  view  of  brace  applied  for 
tuberculosis  of  the  spine  (Brad- 
ford and  Lovett). 


Fig.   36. 

Front  view  of  brace  applied 
for  tuberculosis  of  the  spine 
(Bradford  and  Lovett). 


trouble.      For  example,   it  may  follow  a  suppurative 
tonsillitis,  an  old  ulcerated  tooth,  etc. 

Symptoms. — Unlike  senile  osteo-arthritis  this  form  of 


CHRONIC    DEFORMING    ARTHRITIS  43 

chronic  arthritis  is  accompanied  by  constitutional  symp- 
toms. The  patient  feels  and  looks  ill,  there  may  be 
fever  and  chills.  The  joints  become  swollen,  stiff  and 
painful ;  the  swelling  is  fusiform  in  shape  and  the  skin 
over  it  is  waxy  looking.  The  affected  part  perspires 
profusely  with  a  cold  perspiration.  Deformities  of  the 
various  joints  take  place,  due  to  contractures,  and  the 
patient  may  become  permanently  bedridden. 

Treatment — The  treatment  of  rheumatoid  arthritis 
is  to  remove  the  suppurating  focus,  if  such  can  be 
found  (diseased  tonsil,  ulcerated  tooth,  etc.).  In  cases 
where  the  disease  has  become  quiescent  the  resulting 
deformities  may  be  helped  by  operation. 

Other  deforming  diseases  such  as  gout,  osteitis  defor- 
mans,  multiple  exostoses,  etc.,  are  too  technical  or  too 
common  to  be  more  than  mentioned. 


CHAPTEE  III 

REGIONAL  DEFORMITIES 

The  Neck 

ACQUIRED    WRY-NECK 

Congenital  wry-neck  or  torticollis  was  discussed  in 
the  first  chapter,  but  there  are  also  acquired  forms  of 
this  deformity.  The  most  common  form  of  Acquired 
Wry-Neck  is  that  caused  by  "catching  cold'7  in  the 
neck  muscles,  "stiff  neck"  as  it  is  commonly  called. 
Acquired  wry-neck  is  also  associated  with  traumatism, 
rheumatism,,  rickets,  tuberculosis,  etc.  The  appear- 
ance of  the  acquired  deformity  may  be  the  same  as  that 
of  the  congenital  type  (Fig.  12),  but  the  history  of  the 
onset  will  serve  to  differentiate  the  two.  The  treatment 
of  acquired  wry-neck  is  primarily  the  treatment  of  the 
condition  causing  it. 

In  the  wry-neck  associated  with  "catching  cold"  the 
only  thing  required  is  heat  in  the  form  of  hot  com- 
presses. In  rachitic  wry-neck  the  general  rachitic  con- 
dition may  be  treated,  and  in  the  wry-neck  associated 
with  tuberculosis  the  diseased  cervical  vertebra  must 
be  supported. 

CERVICAL  RIB 

An  extra  rib  may  be  present  in  the  neck,  causing  a 
deformity  known  as  Cervical  Rib.  The  extra  rib  may 

44 


rHE  PACIFIC  CC 
OF 


be  present  on  one  or  both  sides,  and  is  placed  im- 
mediately above  what  would  otherwise  be  the  first  rib 
(Fig.  37)  ;  it  may  press  upon  a  nerve  trunk  and  cause 
symptoms  of  pain  and  paralysis  of  the  arm.  The 


O 

oo  ^ 
<c  oo 

C^^     O^^ 

O    Oi 

•.~^ 

Fig.   37. 

Uu    ^ 

CD  Cervical  rib.     The  arrow  points  to  the  cervical  rib. 

treatment  of  such  a  condition  is  surgical  removal  of 
the  extra  rib. 

The   Chest 

The  important  orthopedic  deformities  of  the  chest 
are  four  in  number  and  are:  rachitic  rosary,  Har- 
rison's groove,  pigeon  breast  and  funnel  chest.  Ka- 
chitic  rosary  and  Harrison's  groove  are  associated  with 
rickets. 


46  ORTHOPEDIC   SURGERY  FOR   NURSES 

RACHITIC  ROSARY 

The  rachitic  rosary  (Fig.  16)  is  -a  beading  of 
the  ribs  at  their  junction  with  the  sternal  cartilages. 
It  is  due  to  the  same  rachitic  process  which  causes  the 
wrists  and  ankles  to  enlarge. 

HARRISON'S  GROOVE 

Harrisons  groove  (Fig.  38)  is  a  longitudinal  fur- 
row across  the  chest  at  the  level  of  the  attachment  of 


Fi&.    38. 
Harrison's   Groove.      The    arrow   points   to    the    groove. 

the  diaphragm.  It  is  supposed  that  the  pull  of  the 
diaphragm  on  the  softened  ribs  causes  them  to  bend 
inward. 


PIGEON    BREAST   AND    FUNNEL    CHEST  47 

PIGEON   BREAST   AND   FUNNEL  CHEST 

Pigeon  Breast  and  Funnel  Chest  (Fig.  39)  are  de- 
formities more  commonly  associated  with  mouth  breath- 
ing in  children;  the  mouth  breathing  being  due  to 
adenoids  or  enlarged  tonsils.  The  fact  that  such  de- 
formities of  the  chest  develop  in  mouth  breathers  is 


Fig.    39. 

Pigeon    breast     and     funnel    chest.       The     child    on     the     right     has 
pigeon  breast  and  the  child  on  the  left  has  funnel  chest. 

one  of  the  several  reasons  why  adenoids  and  enlarged 
tonsils  should  be  diagnosed  early  and  removed. 

The   Spine 

The  common  deformities  of  the  spine  are:  kyphosis, 
round  back;  lordosis,  hollow  back;  scoliosis,  lateral 
curvature. 


48 


ORTHOPEDIC   SURGERY  FOR   NURSES 

KYPHOSIS 


A  simple  Kyphosis  is  an  exaggeration  of  the  slouch- 
ing attitude — the  lazy  attitude — "round  shoulders" 
(Figs.  40,  41).  Children  at  the  most  rapidly  growing 


Fig.     40. 
Round    shoulders     (kyphosis). 


Fig.     41. 
Round   shoulders    (kyphosis). 


age  (eight  to  fourteen  years)  almost  always  have  to 
be  told  to  stand  straight;  if  they  do  not  stand  straight 
the  round  shoulders  or  kyphosis  may  become  a  fixed 
deformity  (Fig.  42).  In  tuberculosis  of  the  spine 
the  deformity  takes  the  form  of  an  angular  kyphosis, 


LORDOSIS 


49 


the  bodies  of  the  vertebrae  crush  down  together  and 
the  spinous  processes  are  pushed  backward,  forming  the 
characteristic  "hunch-back"  (Figs.  25,  26). 

Kyphosis,  unless  checked,  is  a  pro- 
gressive deformity. 

The  treatment  of  simple  kyphosis 
is  to  instruct  the  patient  in  systematic 
exercises  to  strengthen  the  muscles  of 
the  back  and  to  cultivate  an  erect 
posture.  The  tuberculous  kyphosis  re- 
quires special  treatment  by  plaster 
casts,  forcible  correction  or  operation. 

LORDOSIS 

Lordosis,  or  bending  forward  of  the 
spine,  is,  as  a  rule,  a  secondary  defor- 
mity. For  example,  in  double  congen- 
ital dislocation  of  the  hip  the  heads 
of  the  femurs  are  displaced  backward, 
and  to  compensate  for  this  and  allow  5,xeJ*  (structural).' 

Kyphosis    with    corn- 

the  body  to  maintain  the  erect  atti-  Pensatory  lordosis. 
tude,  the  spine  must  bend  forward  in    * 
the  lumbar  region  (Fig.  43).     Lordosis  is  also  present 
as  a  deformity  secondary  to  kyphosis.  If  a  marked  bend- 
ing backward  of  the  spine  is  present  there  must  also 
be  present  a  forward  bending  to  compensate  and  allow 
the  erect  attitude  to  be  maintained   (Fig.  42).     The 
deformity  is  unsightly,  and  on  account  of  the  peculiar 
position  of  the  abdomen  is  apt  to  cause  enteroptosis 
(sagging  of  the  abdominal  organs), 


Fig.     42. 
Round      shoulders, 


50 


ORTHOPEDIC  SURGERY  FOR  KURSES 


The  treatment  of  lordosis  is  attention  to  the  original 
cause  of  the  deformity. 


SCOLIOSIS 

Scoliosis,  or  lateral  curvature  of  the  spine,  is  one  of 
the  most  distressing  deformities  of  orthopedic  surgery. 
It  usually  first  shows  itself  about  the  age 
of  puberty  and  is  more  common  in  girls 
than  in  boys. 

The  cause  of  lateral  curvature  of  the 
spine  is  not  thoroughly  understood;  gen- 
eral weakness  or  rachitic  tendency  seem 
to  be  the  cause  in  some  cases,  at  other 
times  the  deformity  appears  to  develop 
without  any  recognized  cause.  Rapid 
growth,  associated  with  the  age  of  puberty 
and  the  physical  strain  of  school  life, 
aggravate  the  condition,  and  sometimes 
would  seem  to  be  the  principal  etiological 
factor. 

The  symptoms  are  for  the  most  part 
objective,  and  frequently  the  deformity 
is  well  advanced  before  it  is  noticed.  The 
child  may  have  been  listless   and  lazy 
acting,  always  standing  on  one  foot  and 
siting  in  a  slouching  attitude;  then  one 
day  someone  notices  that  one  shoulder  of 
the  child  is  higher  than  the  other  or  one  hip  or  one 
shoulder  blade  is  more  prominent  than  the  other  (Figs. 


Fig.    43. 

Lordosis 
ondary     to 
genital       disloca- 
tion   of    the    hip. 


sec- 
con- 


SCOLIOSIS 


51 


44,  45 ) ,  and  on  closer  examination  the  typical  S-shaped 
curve  of  the  spine  is  found.  A  dressmaker  is  often  the 
first  to  discover  the  deformity  in  a  girl,  it  being  found 
necessary  to  pad  a  shoulder  or  hip  to  make  the  dress 
fit  perfectly. 


Fig.    44. 

Early  stage  of  lateral  cur- 
vature of  the  spine  (scoliosis). 
High  shoulder  and  prominent 
shoulder  blade,  right  side. 


Fig.   45. 

Early  stage  of  lateral  curva- 
ture of  the  spine  (scoliosis). 
Prominent  hip,  right. 


The  tendency  of  the  curvature  is  to  progress  rapidly. 
The  S-shaped  deformity  becomes  very  marked,  and  the 
distortion  of  the  spine  and  ribs  is  so  great  that  the 
heart  and  lungs  are  pressed  upon,  affecting  the  general 


02  ORTHOPEDIC  SURGERY  FOR  NURSES 

health    (Fig.   46).     The  spinal  nerve  trunks  may  be 
pressed  upon  and  irritated  and  cause  severe  pain. 

In  the  early  stages  the  spine  takes  on  the  S-shaped 
deformity,  seemingly  due  to  muscular  weakness,  but 


Fig.     46. 

Advanced       stage       of       lateral 
curvature   of  the  spine    (scoliosis). 


Fig.     47. 


Curvature  of  the  spine, 
(structural)  showing  rotation 
of  the  spine  and  ribs. 


can  be  straightened  by  voluntary  effort  of  the  child.  In 
an  untreated  case  the  child  soon  tires  of  the  voluntary 
effort  to  keep  erect  and  slouches  down  again  into  the 
deformed  position.  As  time  goes  on  the  voluntary 
correction  becomes  impossible,  and  the  curvature  be- 
comes fixed  or  "structural"  as  it  is  called. 


SPONDYLITIS    DEFOKMANS 


53 


Associated  with   structural  curvature  of  the  spine 

there  is  rotation  of  the  spine  and  ribs,  which  is  best 

shown  by  having  the  patient  bend  forward  at  the  waist, 

whereupon   the    rotated    ribs   become   very   prominent 

(Fig.  47). 

Treatment. — Treatment  in  the 
early  stage  consists  of  rest,  tonics, 
good  food,  fresh  air  and  trained 
muscular  exercises  to  strengthen  the 
weakened  muscles.  At  a  later  stage 
correction  of  the  deformity  by 
plaster  casts  may  be  necessary,  and 
in  still  later  stages,  when  actual 
bony  change  has  taken  place,  no 
cure  is  possible. 

The  importance  of  recognizing 
the  condition  at  an  early  stage  can 
readily  be  seen.  A  child  who  is 
listless,  tires  easily,  persistently 
stands  on  one  foot  or  sits  in  a 
slouching  attitude  should  always  be 
suspected  of  having  a  beginning 
curvature  of  the  spine  and  should 

Spondylitis  deformans. 

?AftertwihitmanJ)ttltude  ^     thoroughly    examined    accord- 
ingly. 


SPONDYLITIS   DEFORMANS 

Spondylitis  deformans  is  the  spinal  form  of  senile 
osteo-arthritis.     The  spine  becomes  stiff  and  rigid  and 


54 


ORTHOPEDIC  SURGERY  FOR   NURSES 


is  either  held  perfectly  straight,  "Poker-back,"  or  as  a 
rounded  kyphosis  (Fig.  48). 

Treatment  of  the  condition  is  very  unsatisfactory. 


Fiff.     49. 
Congenital  dislocation  of  the  left  shoulder.     Characteristic  attitude. 

The  Shoulder 
CONGENITAL  DISLOCATION  OF  THE  SHOULDER 

Congenital  Dislocation   of   the   Shoulder  is   not   a 
common  deformity;  but,  when  it  is  present,  it  may  be 


OBSTETRICAL  PARALYSIS 


55 


mistaken  for  obstetrical  paralysis.  The  position  in 
which  the  affected  arm  is  held  is  very  characteristic 
(Fig.  49). 

OBSTETRICAL    PARALYSIS 

Obstetrical  Paralysis  of  the  shoulder  is  an  acquired 
deformity  caused  by   an   injury  to  the  nerve  trunks 


Fig.    50. 

Obstetrical   paralysis  of  the  right   shoulder.     Characteristic  attitude 
(After    Whitman). 


supplying  the  shoulder  and  arm  muscles  at  the  time 
the  child  is  born.  The  injury  is  supposed  to  be  a 
rupture  or  tearing  of  the  nerve  trunks,  and  is  fairly 


56 


ORTHOPEDIC  SURGERY  FOR  NURSES 


common  in  cases  of  difficult  labor  where  the  child  has 
to  be  pulled  upon  in  delivery. 

The  condition  shows  itself  shortly  after  birth  when 
it  is  seen  that  the  child  cannot  use  one  arm  and  it  hangs 
limp  and  "dead"  as  in  infantile  paralysis  (Fig.  50). 


Subdeltoid   bursitis. 


Fin.    51. 


The   sac   of   the   bursa   underneath   the 
deltoid    muscle. 


The  paralysis  may  be  slight  or  extensive,   depending 
upon  the  extent  of  the  injury  to  the  nerve  trunks. 

Treatment  consists  in  supporting  the  affected 
shoulder  and  arm  in  a  bandage,  gentle  massage,  and 
trying  to  make  the  baby  use  the  arm.  Operative  meas- 
ures such  as  nerve  repair,  nerve  anastomosis,  muscle 


BURSITIS  57 

transplantation,  insertion  of  artificial  silk  tendons,  etc., 
have  been  used  in  some  cases. 

BURSITIS 

One  of  the  most  common  acquired  deformities,  or 
rather  disabilities,  of  the  shoulder  is  what  is  known  as 
Sub-Deltoid  Bursitis.  Between  the  deltoid  muscle  (the 
muscle  which  lies  over  the  point  of  the  shoulder  and 
raises  the  arm  from  the  side)  and  the  bone  there  is  a 
small  sac  called  a  bursa ;  it  serves  to  protect  the  muscle 
from  the  bone  (Fig.  51).  Sometimes  due  to  injury 
or  other  causes  the  sac  becomes  inflamed,  causing  a 
bursitis.  The  shoulder  becomes  stiff  and  painful  and 
very  annoying.  The  treatment  of  the  condition  is  rest 
and  heat  to  the  part,  but  sometimes  it  may  become  neces- 
sary to  aspirate  or  dissect  out  the  bursa  before  relief 
is  obtained. 

The  Elbow 

TENNIS  ELBOW 

There  is  an  acquired  disability  of  the  elbow  known 
as,  "Tennis  Elbow."  It  is  supposed  to  be  due  to  a 
periostitis  or  to  an  arthritis  caused  by  playing  tennis  or 
other  similar  exercise.  The  essential  treatment  is  rest 
to  the  joint. 

The  Wrist  and  Hand 

The  wrist  and  hand  may  be  congenitally  deformed 
in  various  ways.  The  deformities  are  very  evident 
when  present,  and  need  no  special  discussion. 


58  ORTHOPEDIC  SURGERY  FOR  NURSES 

VOLKMANN'S   ISCHEMIC   PARALYSIS 

An  acquired  deformity  of  the  wrist  and  hand,  now 
rarely  seen  since  its  cause  has  been  discovered,  is  Volk- 
manns  Ischemic  Paralysis.  This  deformity  is  caused 
by  putting  on  splints  too  tightly  or  not  padding  them 
sufficiently.  The  blood  supply  is  interfered  with  and  the 


Fig.    52. 
Volkmann's    ischemic    paralysis    of    left    arm    and    hand. 

nerves  are  affected,  causing  a  contracture  to  occur  (Fig. 
52).  A  trained  nurse,  whenever  called  upon  to  apply 
an  emergency  splint,  should  bear  in  mind  the  danger 
of  this  deformity,  pad  the  splint  sufficiently,  and  not 
apply  it  too  tightly. 


THE  FINGERS  59 

The  treatment  of  the  deformity  when  it  is  once  es- 
tablished is  very  unsatisfactory. 

GANGLION 

Another  acquired  deformity  of  the  wrist  and  a  very 
common  one  is  what  is  known  as  Ganglion ;  sometimes 
called  "weeping  sinew. "  A  ganglion  is  a  slightly  pain- 
ful globular  swelling  of  the  wrist,  usually  posterior, 
associated  with  more  or  less  weakness  of  the  joint  (Fig. 


Fig.    53. 
Ganglion    of    the    wrist. 

53).  It  is  a  hernia  of  a  tendon  sheath  or  of  the  syno- 
vial  membrane  of  the  wrist  joint  and  the  sac  is  filled 
with  a  clear  gelatinous  material.  Sometimes  the  tumor 
can  be  ruptured  subcutaneously  and  made  to  disappear ; 
in  other  cases  it  is  necessary  to  operate  and  remove 
the  sac. 

The  Fingers 

The  congenital  deformities  of  the  fingers  are  web- 
fingers,  missing  fingers,  extra  fingers,  etc. 


60  ORTHOPEDIC  SURGERY  FOR  NURSES 

DUPUYTREN'S  CONTRACTURE 

Dupuytrens  Contracture  is  an  acquired  deformity 
supposedly  caused  by  an  injury  to  the  palmar  fascia, 
causing  it  to  contract.  As  the  fascia  contracts  it  flexes 


Fig.    54. 
Dupuytren's  contracture. 

first  one  finger  and  then  another  down  into  the  palm  of 
the  hand.  The  ring  finger  is  the  one  usually  first  af- 
fected (Fig.  54). 

The  treatment  of  the  condition  is  to  dissect  out  and 
remove  the  palmar  fascia. 


TRIGGER  FIXGEB 


61 


MALLET  FINGER 

Mallet  Finger  is  an  acquired  deformity  caused  by 
an  injury  to  the  extensor  tendon  of  the  finger.  As  a 
consequence,  the  end  phalanx  drops  forward  and  gives 
the  appearance  of  a  mallet  (Fig.  55). 


Fig.   55. 
Mallet  finger   (fourth   finger). 

Operative  treatment  is  necessary  to  restore  the  in- 
jured tendon. 

TRIGGER  FINGER 

Trigger  Finger  is  an  acquired  disability  in  which,  in 
extension  or  flexion,  the  movement  is  arrested  for  a 
moment  and  then  is  continued  with  a  distinct  and  some- 
times audible  snap.  It  is  due  to  an  obstruction  of  the 
tendon  in  its  sheath.  The  treatment  is  to  remove  the 
cause  of  the  obstruction. 


CHAPTEK  IV 

REGIONAL  DEFORMITIES — Continued 
The  Pelvis 

STRAIN  OF  THE   SACRO-ILIAC  JOINTS 

The  most  common  orthopedic  disability  associated 
with    the    pelvis    is    strain    of    the    sacro-iliac    joints. 


Fig.    56. 

The    pelvis    showing    the    sacro-iliac    joints.       The    arrows    point    to    the 
sacro-il'ac  joints. 

These  joints  are  situated  low  down  in  the  back  at  the 
junction  of  the  sacrum  and  iliac  bones  (Fig.  56),  and 

62 


THE  KNEE  63 

are  subject  to  strain  in  heavy  lifting,  accidents  which 
wrench  the  back,  etc.  The  symptoms  of  strain  are 
pain  and  stiffness  referred  to  the  region  of  the  joints. 
The  pain  may  be  acute  in  character  and  radiate  down 
the  back  of  the  thigh,  resembling  sciatica,  or  it  may 
radiate  in  front  to  the  inguinal  region.  At  other 
times  there  may  be  simply  a  constant  dull  pain  in  the 
lower  back. 

The  treatment  is  rest,  support  to  the  joint  and  in 
very  severe  cases  it  is  sometimes  thought  advisable  to 
operate  and  ankylose  the  joints. 

The  Hip 

Congenital  dislocation  of  the  hip  and  tuberculosis 
of  the  hip,  the  two  most  important  orthopedic  deform- 
ities of  that  region,  have  already  been  discussed. 

The  Knee 

Tuberculosis  of  the  knee  and  chronic  arthritis  of 
the  knee  have  already  been  discussed  under  the  head- 
ing of  "Acquired  Deformities  Caused  by  Disease.77 

There  are  three  important  structural  deformities 
of  the  knee  known  as: 

Genu  valgum  (knock-knee). 

Genu  varum  (bow-legs). 

Genu  recurvatum   (backward  bending). 


64  ORTHOPEDIC  SURGERY  FOR  NURSES 

GENU  VALGUM  AND  GENU  VARUM 

Genu  Valgum  and  Genu  Varum  (Figs.  57,  58)  are 
deformities  usually  associated  with  rickets,  and  are 
objectionable  principally  on  account  of  their  appear- 
ance. In  mild  cases  the  deformity  may  be  outgrown, 


Fig.     57.  Fig.    58. 

Genu  valgum    (knock-knee).          Genu    varum    (bow-legs). 

otherwise  the  crooked  bones  have  to  be  broken, 
straightened  and  held  in  position  by  a  plaster  cast  until 
union  has  taken  place. 


ANTERIOR  BOWING   OF   THE   LEGS 


65 


GENU  RECURVATUM 

Genu  Recurvatum  (Fig.  59)  is  a  deformity  which 
more  commonly  follows  paralytic  conditions.  Braces 
can  be  used  to  hold  the  leg  straight. 


Fig.    59. 
Genu  recurvatum. 


Fig.  60. 

Anterior    bowing    of    the    legs 
(After  Whitman). 


ANTERIOR  BOWING  OF  THE  LEGS 

An  Anterior  Bowing  of  the  Legs  may  occur  as  a 
congenital  affection  or  as  the  result  of  rickets  (Fig. 
CO).  This  particular  deformity  of  the  legs  is  rarely 
"outgrown"  and  correction  has  to  be  made  by  opera- 
tion. A  wedge-shaped  piece  of  bone  is  removed  and 
the  leg  straightened. 


66  ORTHOPEDIC  SURGERY  FOR  NURSES 

HOUSEMAID'S  KNEE 

Housemaid's  Knee,  so-called  because  of  its  frequent 
occurrence  in  housemaids  who  kneel  when  scrubbing,  is 
the  common  name  for  pre-patellar  bursitis.  The  pre- 
patellar  bursa  is  situated  just  in  front  of  the  patella 
(the  knee-cap),  and  when  injured  or  irritated  may  be- 
come inflamed,  swollen  and  very  tender  (Fig.  61). 


Fiff.    61. 

Housemaid's    knee    (pre-patrllar    bursitis). 
(Bradford  and  Lovett). 


Left   knee 


The  treatment  in  mild  cases  is  to  bandage  the  part 
tightly.  Sometimes  it  is  best  to  aspirate  the  contents 
of  the  inflamed  bursa  and  then  apply  a  firm  bandage. 


LOOSE   CARTILAGES  67 

At  other  times,  in  order  to  effect  a  cure,  it  is  necessary 
to  operate  and  remove  the  bursa. 

FLOATING  BODIES 

Floating  Bodies  or  Loose  Bodies  in  the  knee  joint 
are  at  times  the  cause  of  very  severe  disability.  The 
floating  bodies  may  be  small  pieces  of  detached  bone 
following  an  injury;  they  may  be  calcified  portions  of 
detached  synovial  membrane,  calcified  blood  clot,  etc. 
They  move  around  in  the  joint  until  caught  between 
the  bones,  when  they  cause  a  sudden  sharp  pain  and 
locking  of  the  joint;  this  is  usually  followed  by 
swelling  and  an  acute  inflammation.  The  same  con- 
dition may  be  present  in  other  joints,  especially  the 
ankle.  The  treatment  is  removal  of  the  foreign  body 
by  a  surgical  operation. 

LOOSE  CARTILAGES 

Within  the  knee  joint  there  are  two  crescent  shaped 
discs  of  cartilage  known  as  the  semilunar  cartilages 
(internal  and  external).  They  are  attached  to  the 
upper  surface  of  the  head  of  the  tibia  and  to  the  cap- 
sule of  the  joint.  Due  to  a  wrench  or  strain  of  the 
knee  joint  one  or  both  of  these  cartilages  may  become 
detached  and  cause  a  severe  disability  of  the  knee. 

Loose  Cartilages  of  the  knee  joint  give  practically 
the  same  symptoms  as  floating  bodies,  and  the  differen- 
tial diagnosis  between  the  two  conditions  is  often  very 
difficult.  The  treatment  of  loose  cartilages  of  the  knee 


68  ORTHOPEDIC  SURGERY  FOR   NURSES 

joint  is  first  to  manipulate  them  back  into  place  and 
then  support  the  knee  until  the  cartilages  become  fixed. 
If,  as  sometimes  happens,  the  cartilages  do  not  reat- 
tach  themselves,  but  remain  loose,  it  is  necessary  to 
remove  them  to  prevent  the  constant  annoyance  of 
having  them  get  caught  between  the  bones. 

The  Foot 

One  of  the  most  important  acquired  disabilities  and 
deformities  of  the  foot  is  weak  foot,  but  that  particular 
disability  and  deformity  will  be  discussed  in  a  chapter 
by  itself. 

There  are  numerous  congenital  deformities  of  the 
foot,  which  can  be  recognized  when  seen;  one  of  these 
is  what  is  known  as  lobster  claw  deformity.  No  dis- 
cussion is  necessary.  The  most  important  congenital 
deformity  of  the  foot  is  club  foot,  which  has  already 
been  discussed. 

ACQUIRED  CLUB  FOOT 

Acquired  Club  Foot  is  usually  due  to  paralytic  dis- 
ease ;  the  foot  being  drawn  into  a  deformed  position  by 
the  action  of  unopposed  muscles  or  by  contractures 
The  treatment  is  operative. 

PIGEON  TOE 

Pigeon  Toe  is  a  deformity  rather  common  in  chil- 
dren, and  in  a  great  many  cases  it  is  due  to  the  fact 


EXOSTOSIS  OF  THE  OS  CALCIS  69 

that  the  child  is  suffering  from  weak  arches.  The 
toeing  in  is  the  result  of  Nature's  effort  to  raise  the  arch 
of  the  foot.  This  can  he  easily  illustrated  by  turning 
in  the  toes,  when  it  will  be  seen  that  the  arch  of  the 
foot  is  raised.  Mild  cases  of  toeing  in  will  clear  up  of 
themselves.  Supporting  the  weakened  arches  of  the 
feet  will  cure  other  cases.  When  the  toeing  in  is  a 
habit  and  not  due  to  weak  arches,  building  up  the  outer 
edge  of  the  sole  of  the  shoe  will  stop  it. 

The  Heel 
BURSITIS 

Bursitis,  sometimes  known  as  "policeman's  heel,"  is 
a  disability  that  may  be  present  in  people  who  walk  or 
stand  a  great  deal  on  hard  surfaces.  Just  as  in  the 
shoulder  and  knee,  the  bursa  under  the  heel  becomes 
inflamed  and  causes  very  severe  pain  when  pressure  is 
put  upon  it.  The  treatment  is  rest,  removal  of  the 
weight  of  the  body  from  the  heel  by  the  use  of  arch 
supports,  and  in  persistent  cases  removal  of  the  sac 
of  the  bursa. 

EXOSTOSIS  OF  THE  OS  CALCIS 

Exostosis  of  the  Os  Calcis  is  the  name  given  to  a  small 
spicule  of  bone  growing  out  from  the  under  surface  of 
4he  heel  bone  (the  os  calcis — see  Fig.  62).  The  cause 
of  the  exostosis  is  variable:  it  may  follow  an  injury  or 
an  acute  infectious  disease  such  as  influenza,  or  it  may 


O  ORTHOPEDIC  SURGERY  FOR   NURSES 

be  a  reaction  to  constant  irritation,  like  standing  day 
after  day  on  a  hard  cement  floor.  The  principal  symp- 
tom of  exostosis  of  the  os  calcis  is  a  pain  -underneath 
and  to  the  inner  side  of  the  heel  every  time  weight  is 


Fig.    62. 


Exostosis  of  the  os  calcis.      The   arrow  points  to    the   exostosis, 
which    is   an    unusually    large    one. 

borne  on  the  foot.  On  standing  there  is  a  burning, 
sticking  pain  in  the  heel.  The  treatment  is  to  remove 
the  exostosis. 

The  Toes 

Congenital  malformations  consist  of  webbed  toes, 
missing  toes,  extra  toes,  etc. 

The  great  toe  is  subject  to  three  structural  deformi- 
ties known  as : 


HALLUX  VALGUS  71 

Hallux  valgus  (toe  turned  out). 
Hallux  varus   (toe  turned  in). 

Hallux  rigidus  (toe  turned  up  or  down  and  held 
rigid). 

HALLUX  VALGUS 

Hallux  Valgus,  or  bunion,  which  is  the  common  name 
for  the  deformity,  is  the  most  frequent  deformity  of 
the  great  toe.  It  is  a  condition  usually  associated  with 
"weak  feet/'  arid  is  often  caused  by  wearing  shoes  too 


Fiff.     63. 
Hallux    valgus    (bunion). 


narrow  across  the  ball  of  the  foot  or  with  too  pointed 
a  toe  (Fig.  71).  It  is  a  "fashion  deformity."  The 
great  toe  is  turned  outward  and  the  metatarsophalan- 
geal  joint  becomes  enlarged,  painful  and  inflamed, 
forming  a  bunion  (Fig.  63). 

The  treatment  is,  first  of  all,  to  supply  the  patient 
with  proper  shoes — shoes  that  do  not  compress  the  ball 
of  the  foot  or  turn  the  great  toe  outward.  In  some 


72  ORTHOPEDIC   SURGERY  FOR   NURSES 

cases  an  arch  support  which  removes  some  of  the 
weight  of  the  body  from  the  inflamed  joint  will  effect 
a  cure.  Radical  treatment  consists  in  removing  the 
head  of  the  first  metatarsal  bone.  When  properly 
performed  this  is  a  very  satisfactory  operation. 

HALLUX  VARUS 

Hallux  Varus  (Fig.  64)  is  frequently  a  congenital 
deformity,  but  may  be  caused  by  paralytic  diseases. 
The  treatment  is  surgical. 


Fig.     64. 
Hallux    varus     (congenital). 


HALLUX  RIGIDUS 

Hallux  Rigidus  is,  properly  speaking,  a  form  of 
osteo-arthritis,  but  is  also  frequently  associated  w^ith 
" weak-feet."  The  bony  edges  of  the  great  toe  joint  be- 
come roughened  and  bony  spicules  may  form,  and  the 


HAMMER    TOE  T6 

joint  becomes  painful  and  more  or  less  ankylosed  (Fig. 
65). 

In  very  mild  cases  treatment  may  consist  in  stiff  ening 
the  sole  of  the  shoe  underneath  the  inflamed  joint,  thus 
preventing  excessive  motion.  In  severe  cases  it  is 
necessary  to  operate  and  resect  the  joint. 


Figr.     65. 
Hallux     rigidus. 


Fiff.    66. 
Hammer    toe     (the    second    toe). 


HAMMER  TOE 

Hammer  Toe  (Fig.  66)  is  due  to  a  drawing  up  of 
one  toe,  a  contraction  of  the  ligaments  and  tendons.  It 
may  be  congenital  or  may  be  associated  directly  or  in- 
directly with  "weak  feet." 

In  children  a  cure  can  sometimes  be  obtained  by 
cutting  the  contracted  tissues  and  keeping  the  toe 


74  ORTHOPEDIC   SURGERY  FOR   NURSES 

straight  in  a  splint  for  some  time.     In  adults  it  may 
be  best  to  remove  the  offending  toe. 

TRIGGER  TOE 

Trigger  Toe  has  the  same  causes,  symptoms  and  treat- 
ment as  trigger  finger,  which  has  already  been  dis- 
cussed. 


O 
O 


00 
<C  CO 

o  oc 

O   -^ 


55 


ANTERIOR  METATARSALGIA  AND  MORTON'S  TOE 

The  heads  of  the  metatarsal  bones  form  what  is 
known  as  the  anterior  arch  of  the  foot,  and,  when  this 
arch  is  strained  or  depressed,  it  causes  a  pain  in  the 


FiR.    67. 
Callus  formation  on  sole  of  feet  in  anterior  metatarsalgia. 

front  part  of  the  foot  known  as  Anterior  Metatarsalgia. 
Evidence  of  the  depressed  anterior  arch  is  frequently 
shown  by  callus  formation  on  the  ball  of  the  foot  (Fig. 
67). 


ANTERIOR  METATARSALGIA  AND   MORTON'S    TOE       75 

Mortons  Toe  is  a  severe  pain  or  cramp  in  one  of  the 
toes,  more  often  the  fourth.  It  comes  on  while  the 
patient  is  walking,  and  is  sometimes  so  severe  that  the 
patient  has  to  stop,  remove  the  shoe  and  massage  the 
foot.  It  is  supposed  to  be  due  to  the  head  of  the  meta- 
tarsal  bone  pressing  on  a  nerve. 

In  mild  cases  relief  may  be  obtained  by  supporting 
the  heads  of  the  metatarsal  bones  by  an  anterior  arch 
support.  In  severe  cases  it  is  necessary  to  remove  the 
head  of  the  metatarsal  bone  causing  the  trouble. 


A<x" 


CHAPTEK  V 
WEAK  FEET 

4) 

A  nurse  in  training  sooner  or  later  realizes  the  im- 
portance of  having  her  feet  always  in  proper  condition. 
Ordinarily  she  is  apt  to  forget  and  neglect  her  feet, 
packed  away,  as  they  are,  in  leather  cases  at  the  farthest 
possible  distance  from  her  brain  centers;  but  they  are 
nevertheless  very  important  parts  of  her  body.  The}r 
deserve  her  constant  care  and  attention,  for  if  they 
suffer,  her  whole  body  will  suffer  with  them. 

Foot  troubles  are  almost  unknown  among  bare-footed 
savages,  but  in  our  modern  civilization  practically  the 
only  examples  of  perfect  feet  are  found  in  babies.  The 
great  majority  of  babies  have  perfect  feet.  Some  un- 
fortunate babies  are  born  with  deformed  feet  or  suffer 
from  paralyzing  and  deforming  diseases  later,  but  such 
cases  have  already  been  discussed.  The  fact  is  that 
most  individuals  begin  life  with  normal  feet.  Why  then 
is  foot  trouble  so  prevalent  ? 

Dr.  Hoffman,  an  orthopedic  surgeon  in  St.  Louis,  at 
the  time  of  the  World's  Fair,  experimented  with  the 
feet  of  bare-footed  savages.  He  supplied  the  savages 
with  what  seemed  to  be  perfectly  fitting  modern  foot- 
wear and  found  that  in  a  very  short  time  all  the 
savages  began  to  experience  more  or  less  foot  trouble. 

76 


WEAK  FEET  77 

Some  one  unknown  to  the  writer  has  composed  a 
alimerick"  which  goes  something  like  this: 

A  dashing  young  brave  of  the  Sioux 
Tried  to  walk  in  a  paleface's  shoe; 

But  it  caused  so  much  woe 
To  his  primitive  toe, 

He  stopped  it  without  much  ado. 

The  conclusion  is  that  the  modern  shoe  is  the  prime 
factor  in  causing  foot  troubles.  Why  is  this  so? 

The  foot  is  a  complicated  structure  made  up  of  nu- 
merous bones,  ligaments,  muscles,  bloodvessels,  nerves, 
etc.,  all  moulded  together  to  form  a  support  to  the  body, 
strong  and  steady,  and  yet  at  the  same  time  flexible 
and  capable  of  motion.  Mechanically  considered,  the 
foot  is  a  wonderful  piece  of  machinery. 

It  can  readily  be  understood  how  detrimental  it 
would  be  to  an  intricate  machine  to  have  anything 
interfere  with  its  proper  working ;  how  easily  under  such 
conditions  its  parts  could  be  injured  and  strained  and 
its  strength  and  efficiency  impaired.  Now  just  that 
sort  of  thing  can  happen  to  the  foot  and  that  is  just 
the  state  of  affairs  when  it  is  compelled  to  work  in  a 
faulty  shoe. 

A  shoe  may  be  faulty  in  various  ways.  The  heel 
may  be  too  high  or  too  low,  throwing  the  weight  of 
the  body  too  far  forward  or  too  far  back.  The  inner 
sole  of  the  shoe  may  not  be  large  enough  to  support  the 
weight-bearing  surface  of  the  foot  (Fig.  68).  The 
shoe  may  exert  undue  pressure  at  some  points,  allow- 
ing too  much  play  at  other  points  and  be  very  un- 


78 


ORTHOPEDIC  SURGERY  FOR  NURSES 


comfortable  in  consequence.  Lastly,  the  shape  of  the 
shoe  may  be  such  that  the  foot  is  held  in  an  abnormal 
position  that  tends  to  cause  deformity.  Each  and  all 
of  these  features  of  a  faulty  shoe  cause  a  constant  strain 
and  loss  of  strength  and  efficiency  in  the  working  foot. 


Fig.   68. 

Illustration  of  a  faulty  shoe.  The  inner  sole  of  the  shoe  is  not 
large  enough  to  accommodate  the  foot.  The  figure  on  the  right  shows 
the  foot  compressed  in  the  shoe  outline.  The  figure  on  the  left  shows 
the  position  that  the  foot  takes  when  the  upper  of  the  shoe  is  cut  away. 

Fortunately  the  foot  is  naturally  strong  and  is 
usually  able  to  resist  these  injuries  and  strains  for  a 
long  time.  When,  however,  in  addition  to  the  effect 
of  a  faulty  shoe,  there  is  an  added  effect  of  increased 
weight  of  the  body,  excessive  use  of  the  feet,  a  debilitat- 


FKKT  79 


ing  illness  weakening  the  muscles  and  ligaments,  or 
direct  injury  to  the  foot,  such  as  a  severe  sprain  or 
contusion,  the  foot  gives  way  and  the  symptoms  of 
aweak  feet"  begin. 

Corns,  calluses  and  a  tired  feeling  are  nature's 
danger  signals  to  the  feet,  but  how  often  they  are  dis- 
regarded. •  Corns  and  calluses  are  more  often  con- 
sidered as  a  matter  of  course,  notwithstanding  the  fact 
that  there  is  no  more  reason  why  a  foot  should  have 
corns  than  that  a  baby  should  have  pimples.  Both  show 
that  something  is  wrong.  Tired  feeling  in  the  feet  and 
the  nervous  irritability  that  goes  with  it  are  frequently 
attributed  to  every  condition  except  the  true  one. 
Many  cases  of  so-called  laziness,  loss  of  ambition,  bad 
temper,  incompatibility  of  temperament  in  the  married 
state,  etc.,  may  in  reality  be  beginning  "weak  feet." 

Aside  from  the  danger  signals,  pain  is  the  first 
symptom  of  "weak  feet."  The  pain  may  be  located  in 
the  longitudinal  arch  of  the  foot,  in  the  ball  of  the  foot, 
in  the  ankle  or  in  fact  almost  anywhere  in  the  foot.  In 
some  cases  pain  first  shows  itself  in  the  leg,  knee,  thigh 
or  even  in  the  back.  The  cause  of  the  pain  in  the  early 
stage  of  "weak  feet'7  is  muscular  or  ligamentous  strain. 

An  examination  of  the  foot  at  this  time  may  show 
an  abnormal  position  during  weight  bearing.  The 
foot  may  be  turned  outward,  rolled  in  at  the  ankle, 
prominent  inward  and  downward  at  the  instep  (Fig. 
69),  or  flattened  across  the  ball  with  marked  callus 
formation  (Fig.  67)  —  all  evidences  of  the  strained 
condition  of  the  longitudinal  and  anterior  arches. 


80 


ORTHOPEDIC   SURGERY   FOR   NURSES 


Sometimes  the  effect  of  strain  on  the  foot  is  to  cause 
irritability  and  spasm  of  the  muscles  and  the  foot  be- 
comes contracted  rather  than  flat.  The  longitudinal 
arch  becomes  abnormally  high  and  the  toes  are  drawn 
up  like  claws.  This  is  the  condition  known  as  con- 
tracted foot  and  is  frequently  associated  with  the  use 
of  shoes  with  too  high  a  heel  (Fig.  70). 


Fig.   69. 
Weak  feet. 


Hallux  valgus,  Morton's  toe  and  hammer  toe,  con- 
ditions already  discussed,  may  develop  at  this  and  other 
stages  of  "weak  feet." 

In  all  cases  of  aweak  feet,"  as  the  strain  continues 
the  pain  increases.  The  foot  becomes  swollen  and 
tender  to  the  touch,  muscular  spasm  and  cramps  may 
be  present  and  the  appearance  of  the  foot  is  such  that  a 
diagnosis  of  rheumatism  or  even  tuberculosis  may  be 


WEAK  FEET 


81 


made.    Later  still, 
club-foot,    occurs, 
possible. 

Sucb,  in  brief, 
path  of  the  weak- 
avoid  such  a  fate ; 
way  that  leads  to 
strong  foothold? 

First  of  all,  if  he  cannot  save  himself  he  may  at 


actual  bony  deformity,  an  acquired 
and    walking    becomes    almost    mi- 
is  the  description  of  the  downward 
-footed.     How  shall  the  individual 
or,  having  once  started  on  the  broad 
destruction,  how  shall  he  regain  a 


Fig.    70. 
Contracted    foot. 

least  save  others.  Children  should  be  protected  against 
the  strain  of  faulty  shoes.  Babies'  shoes  should  be  large 
enough — fortunately  almost  all  baby  shoes  on  the  mar- 
ket are  of  good  shape.  Growing  girls  and  boys  should  be 
instructed  to  stand  and  walk  with  the  feet  straight 
ahead  and  the  shoes  should  conform  in  shape  to  ortho- 
pedic principles,  having  broad  toes,  sufficient  width  at 


ORTHOPEDIC  SUKGEKY  FOB  NUKSES 


the  ball  of  the  foot,  very  moderately  high  heels  with 
the  general  shape  such  that  the  foot  is  held  in  a  per- 
fectly natural  position  and  not  with  the  front  part 
turned  outward,  as  is  apt  to  be  the  case  in  straight-last 
narrow-toed  shoes  (Fig.  71).  Probably  the  greatest 


Fiff.     71. 
Faulty  shoe  causing  hallux  valgus. 


danger  to  the  feet  comes  at  the  age  when  a  boy  begins 
to  call  on  his  "best  girl"  and  when  a  girl  begins  to 
attend  parties.  There  is  a  desire  to  make  the  feet  look 
small  and  smart  and  all  manner  of  faultv  footwear 


WEAK  FEET  83 

are  forced  upon  the  unwilling  but  yielding  extremities. 
It  is  at  this  critical  time,  when  the  feet  are  not  fully 
developed  and  are  still  very  susceptible  to  deforming 
influences,  that  much  harm  is  done,  the  effects  of  which 
may  not  show  until  later. 

In  adult  life  the  foot  is  not  so  susceptible  to  de- 
forming influences.  The  wearing  of  faulty  shoes  calls 
attention  to  itself  much  quicker  by  causing  pain;  but 
if  persisted  in,  the  effects  are  the  same  as  in  younger 
people.  The  slogan  for  preventing  "weak  feet"  at  all 
ages  is :  "Wear  proper  shoes." 

After  foot  trouble  has  started,  the  first  procedure  to 
obtain  relief  is  to  provide  proper  shoes.  Then,  if 
possible,  remove  the  contributing  cause  (excessive 
weight,  excessive  use,  etc.),  practice  correct  walking 
and  standing  with  the  feet  straight  ahead,  not  turned 
outward  (Fig.  72),  and  take  special  exercises  to 
strengthen  the  foot,  such  as  rising  on  tip-toe  and  coming 
down  on  the  outer  side  of  the  foot.  A  simple  proced- 
ure and  one  that  rests  tired  feet  a  great  deal  is  to  sit 
with  the  feet  crossed,  the  weight  resting  on  the  outer 
side.  Building  up  the  inner  side  of  the  sole  of  the 
shoe,  so  as  to  throw  the  weight  to  the  outer  side  of  the 
foot  is  often  very  effectual  in  relieving  foot  strain.  In 
early  cases  of  "weak  feet"  the  above  measures  will 
effect  a  cure. 

When  the  strain  on  the  foot  is  more  acute  or  more 
pronounced,  it  may  be  necessary  to  manipulate  the  foot 
and  strap  it  into  an  overcorrected  position  as  a  pre- 
liminary to  the  above-described  procedures.  Strap- 


04  ORTHOPEDIC  SUBGERY  FOB  NUBSES 

ping  the  foot  into  the  adducted  or  overcorrected  posi- 
tion relieves  the  strained  muscles  and  ligaments  and 
gives  the  foot  a  chance  to  recover  its  strength.  When 
the  strain  on  the  foot  is  still  greater,  and  cannot  be  re- 
lieved by  strapping,  it  is  necessary  to  have  an  arch 


Fig.    72. 

Proper  and  improper  position  of  the  feet  in  walking.  When  the 
feet  are  held  straight  ahead  the  line  of  body  weight  falls  through 
the  center  of  the  knee,  ankle  and  foot  and  the  greatest  amount  of 
strength  and  efficiency  is  attained.  When  the  feet  are  turned  outward 
the  line  of  body  weight  falls  to  the  inner  side  and  the  arch  of  the 
foot  is  constantly  strained  and  the  strength  and  efficiency  of  the  foot 
suffer  in  consequence  (After  Whitman). 

support  made.  The  arch  support  holds  the  foot  in  its 
correct  position  and  allows  it  to  work  and  strengthen 
itself  without  strain.  In  conditions  associated  with 
pain,  swelling,  tenderness,  muscle  spasm  and  deformity, 
it  is  sometimes  necessary  to  correct  the  deformity  under 
ether  and  put  the  foot  in  a  plaster-of-Paris  cast  for  a 


WEAK  FEET  85 

time.     Such  cases  should  wear  arch  supports  after  the 
cast  is  removed. 

In  the  severest  type  of  "weak  feet"  a  condition  known 
as  rigid  flat-foot,  where  actual  bony  deformity  and  dis- 
tortion have  taken  place,  it  is  almost  impossible  to  effect 
a  cure.  Operative  interference  and  the  wearing  of  arch 
supports  are  sometimes  of  benefit,  but  the  prognosis  is 
always  doubtful. 


INDEX 


Abdomen,   appearance   of,    in 

rickets,  26 
enlargement  of,  in  rickets, 

25 

Abnormally  formed  bones,  de- 
formity from,  23 
placed      bones,      deformity 

from,  23 

Abscess  formation  in  bone  tu- 
berculosis, 38 
Acetabulum,  17 
Acquired  club-foot,  68 
deformities,  11 

caused    by    disease,    24 
wry-neck,  44 
Adhesive  strapping  in  talipes, 

16 

Anterior      poliomyelitis,      29. 

See  also  Infantile  Paralysis 

Arch  supports  for  hallux  val- 

gus,  72 

for  weak  feet,  84 
Arthritis,  chronic  deforming, 

41 

rheumatoid,  42 
Asymmetry    of    development, 

22 

unilateral,  23 
Athetoid  movements  in  birth 

palsy,  32 
Atrophy  in  birth  palsy,  32 


Atrophy   in   infantile   paraly- 
sis,  30 

BACILLUS  tuberculosis,  32 
Birth  palsy,  31 

athetoid    movements     in, 

32 

atrophy  in,  32 
causes,  32 
characteristic  attitude  in, 

31 

feeble-mindedness   in,   32 
infantile     paralysis     and, 

32 
loss   of   co-ordination   in, 

32 

prognosis,  32 
spasm  in,  31 
symptoms,  32 
treatment,  32 

Bloodless    method     of    treat- 
ment for  dislocation  of  hip, 
18,  19 
Bone    tuberculosis,    32.      See 

also  Pott's  disease 
Bradford  frame  in,  39 
cause,  32 
deformity  in,  33 

cause  of,  38. 

discharging  sinus  in,  38 
fresh  air  in,  39 
good  food  in,  39 


87 


88 


INDEX 


Bone      tuberculosis,      muscle 

spasm  in,  33 
night  cries  in,  34 
operative  treatment,  41 
pain  in,  33 
prognosis,  38,  41 
proper  diet  in,  39 
recognition  of,  38 
rest  in,  39 
running  sores  in,  38 
symptoms,  33 
tenderness  in,  33 
treatment,  39 
Whitman  frame  in,  39 
wry-neck  from,  44 
Bones,    abnormal    growth   of, 

in  rickets,  25 
softness  of,  25,  27 
cartilage  of,  25 
composition  of,  24 
epiphyses  of,  25 
formed  abnormally,  23 
lime  salts  of,  24 
missing,  23 
ossification  of,  25 
placed  abnormally,  23 
supernumerary,  23 
Bowing  of  legs,  anterior,  65 
Bow-legs,  63,  64 
anterior,  65 
in  rickets,  26,  27,  28 
Braces  for  Pott's  disease,  42 
in  infantile  paralysis,  30 
Bradford  frame,  39,  40 
Bunion,  71.     See  also  Hallux 

valgus 
Bursitis,  69 


Bursitis,   prepatellar,   66 
subdeltoid,    56,   57 

CALLUSES,  79 

Cartilage,  loose,  in  knee-joint, 

67 
of  bones,  25 

Cervical  rib,  44,  45 
location,   45 
treatment,  45 

Chest,  deformities  of,  45 

Club-foot,       12.         See       also 

Talipes 
acquired,  68 

Congenital  club-foot,  14 
deformities,  11 
dislocation  of  hip,  17 
malformation  of  toes,  70 
orthopedic  deformities,  12 
wry-neck,     21.       See     also 
Torticollis 

Contracted    feet,    80 

Contractions    in    tuberculosis 
of  knee,  37 

Contracture,  Dupuytren's,  60 
in  infantile  paralysis,  29 

Convulsions  in  infantile  par- 
alysis, 29 

Co-ordination,     loss     of,      in 
birth  palsy,  32 

Corns,  79 

Curvature,   lateral,    of    spine, 
50.     See  also  Scoliosis 

DEFORMING  arthritis,  chronic, 

41 
Deformities,  acquired,  11 


INDEX 


89 


Deformities     caused    by    dis- 
ease,  24 

cause  of,   in   bone   tubercu- 
losis,  38 

congenital,    11 

contracting,      in      infantile 
paralysis,  29,  30 

early  recognition  of,  23 

from  missing  bones,  23 

from  softness  of  bones,  28 

in  bone  tuberculosis,  33 

in  hip  tuberculosis,  36 

in  Pott's  disease,  33—37 

in  rheumatoid  arthritis,  43 

in  weak  feet,  81,  85 

of  chest,  45 

of  feet,  68 

of  fingers,  59 

of  hand,  57 

of  hip,  63 

of  neck,   44 

of  pelvis,  62 

of  shoulder,  54 

of  spine,  47 

of  toes,  70 

of  wrist,  57 

orthopedic  congenital,  12 

examples  of,  11 

postural,  in  rickets,  27,  28 

regional,  44,  62 

spinal,  in  rickets,  27 

structural,  of  knee,  63 

swelling,  in  tuberculosis  of 

knee,  37 
Dentition,  delayed,  in  rickets, 

27 
Development,    asymmetry   of, 

22 


Diet  in  bone  tuberculosis,  39 
Disabilities  of  feet,  68 
of  elbow,  57 
of  heel,  69 
Dislocation  of  hip,  congenital, 

17 
characteristic     attitude 

in,  19 

characteristics  of,  17 
course  when  untreated, 

18 

double,  lordosis  in,  49 
duck-like  waddle  in,  17 
frequency  of,  17 
frog  position  of  cast  in, 

19,  20 
gait  in,  17 
importance      of      early 

treatment  in,  20 
plaster-of-Paris  cast  for, 

19 

prognosis  in,  20 
recognition  of,  17 
symptoms,  17 
treatment,  18,  19 

by  bloodless  method, 

18,   19 
by     Lorenz     method, 

18,  19 
by  open   method,   18, 

19 

x-ray  picture  of,  18 
of  shoulder,  congenital,  54 
characteristic     attitude 

in,  54 

obstetric  paralysis  and, 
55 


90 


INDEX 


Dorsal  spine,  tuberculosis  of, 

34 

Dupuytren's    contracture,    GO 
causes,  60 
treatment,  60 

ELBOW,  disability  of,  57 

tennis,  57 

Electricity  in  infantile  paraly- 
sis, 30 
Enteroptosis     from     lordosis, 

49 
Epiphyses  of  bones,  25 

in  rickets,  26 
Exercises  for  scoliosis,  53 

for  weak  feet,  83 
Exostosis  of  os  calcis,  69 
causes,  69 
from  influenza,  69 
symptoms,  70 
treatment,  70 

FAULTY  shoes,  77 

examples  of,  78 
Feeble-mindedness     in     birth 

palsy,  32 

Feet,  contracted,  80 
deformities  of,  68 
disabilities  of,  68 
effects  of  strain  on,  80 
healthy,  importance  of,  76 
improper     position     of,     in 

walking,   84 
mechanism  of,  77 
of    savages,    Hoffman's    ex- 
periments on,  76 
proper  position  of,  in  walk- 
ing, 84 


Feet,  resistant  powers  of,  78 
troubles,  among  savages,  76 
from  modern  shoes,  77 
prevalence   of,   76 
weak,   76.     See   also   Weak 

feet 
Fever   in   infantile  paralysis, 

29 

in  rheumatoid  arthrits,  43 
Finger,  mallet,  61 
trigger,  61 
deformities  of,  59 
Flat-foot,   rigid,    85 
Floating  bodies  in  knee-joint, 

67 

Fontanelle,  anterior,  in  rick- 
ets, 26 
Foot,     club,     12.       See     also 

Talipes 

effect  of  talipes  on  develop- 
ment of,  15 

troubles,  prevalence  of,  76 
Forehead,  shape  of,  in  rickets, 

26 

Fresh  air  in  bone  tuberculo- 
sis, 39 

in  scoliosis,  53 

Frog  position  of  cast  in  dislo- 
cation of  hip,  19,  20 
Funnel-chest,  47 
causes,  47 

GANGLIOX  of  wrist,  59 
Genu  recurvatum,  65 

valgum,  63,  64 

varum,  63,  64 
Groove,  Harrison's,  46 
Growing  pains  in  children,  38 


INDEX 


91 


HALLUX  rigidus,  72 

treatment,  73 
valgus,   71 

arch  supports  in,  72 
causes,  71 

from  faulty  shoes,  82 
from  weak  feet,  80 
operative  treatment,  72 
treatment,  71 
varus,  72 
Hammer-toe,  73 
causes,  73 
from  weak  feet,  80 
treatment,  73,  74 
Hand,  deformities  of,  57 
Harrison's  groove,  4G 
Heberden's  nodes,  41 
Heel,  disability  of,  69 

policeman's,  69 
Hip,  deformities  of,  63 
dislocation    of,    congenital, 
17.     See  also  Dislocation 
of  hip,   congenital 
tuberculosis  of,  35.  See  also 

Tuberculosis  of  hip 
Hoffman's      experiments      on 

feet  of  savages,  76 
Hot   compresses    in    acquired 

wry-neck,  44 
Housemaid's  knee,  66 
causes,  66 
treatment,  66 
Hunch-back,  49 

INFANT     feeding,    importance 

of,  25 

recognition  of  club  foot  in, 
15 


Infantile  paralysis,  29 

atrophy  in,  30 

and      birth      palsy,      dif- 
ference, 32 

braces  in,  30 

contracture  deformity  in, 
29,   30 

contracture  in,  29 

convulsions  in,  29 

electricity  in,  30 

fever  in,  29 

flaccid  type,  29 

germ  origin  of,  29 

massage  in,  30 

muscle  training  in,  30 

surgical  treatment,  30 

symptoms,  29 

treatment,  30 
Influenza,     exostosis     of     os 

calcis  from,  69 
Ischemic       paralysis,      Volk- 

mann's,  58 
Italian  children,  rickets  in,  24 

JOINT  swelling  in  rheumatoid 

arthritis,  43 
Joints,  tuberculosis  of,  37 

KNEE,  housemaid's,  66 
structural     deformities     of, 

63 
tuberculosis  of,  37.    See  also 

Tuberculosis  of  knee 
Knee-joint,  floating  bodies,  67 
loose  cartilages  in,  67 
senile  osteo-arthritis  in,  41 
Knock-knee,  63,  64 


INDEX 


Kyphosis,  48 
in  Pott's  disease,  36,  48 
in  rickets,  27 

lordosis  secondary  to,  49,  50 
rounded,  in  spondylitis  de- 

formans,  54 
treatment,  49 

LIME  salts  of  bones,  25 
Little's  disease,  31.     See  also 

Birth  palsy 
Liver,     enlargement     of,     in 

rickets,  26 
Loose  cartilages  in  knee-.ioint, 

67 
Lordosis,  49 

enteroptosis  from,  49 

in  double  congenital  dislo- 
cation of  hip,  49 

in  rickets,  25,  26 

secondary   to   kyphosis,    49, 
50 

treatment,  50 
Lorenz  method   of   treatment 

of  dislocation  of  hip,  18,  19 

MALLET-FINGER,  61 
cause,  61 
treatment,  61 

Massage   in   infantile   paraly- 
sis, 30 

in  obstetric  paralysis,  5G 
Metatarsalgia,  anterior,  74 
causes,  74 
treatment,  75 

Missing       bones,       deformity 
from,  23 


Morton's  toe,  75 
causes,  75 
from  weak  feet,  80 
treatment,  75 

Muscle  spasm  in  bone  tuber- 
culosis, 33 

in  hip  tuberculosis,  36 
in  Pott's  disease,  35 
in   tuberculosis   of   knee, 

37 

training  in  infantile  paraly- 
sis, 30 
Muscular  exercises  in  scolio- 

sis,  53 
for  weak  feet,  83 

NECK,  deformities  of,  44 
stiff,  44.    See  also  Wry-neck, 

acquired 

Negro  children,  rickets  in,  24 
Night  cries  in  bone  tubercu- 
losis, 34 

OBSTETRIC    paralysis,    causes, 

55 
characteristic  attitude  in, 

55 
congenital   dislocation  of 

shoulder  and,  55 
involvement  of  arm  in,  56 
massage  in,  56 
operative  treatment,  56 
rupture    of    nerve-trunks 

in,  55 

treatment,  56 

Open  method  of  treatment  of 
dislocation  of  hip,  18,  19 


INDEX 


93 


Orthopedic    deformities,    con- 
genital,  12 
examples  of,  11 
surgery,  definition  of,  11 
Os  calcis,  exostosis  of,  69 
Ossification,  25 
Osteo-arthritis,   senile,   41 
Heberden's,  nodes  in,  41 
in  knee-joints,  41 
parts  affected  by,  41 
prevalence  of,  41 
spinal  form,  53.     See  also 
Spondylitis    deformans, 
treatment,  42 

Overcorrection    in    wry-neck, 
21,  22 

PAIN  in  hip  tuberculosis,  35 
in  Pott's  disease,  34 
in  tuberculosis  of  bones,  33 

of  knee,  37 
in  weak  feet,  79 
Pains,  growing,  38 
Palsy,  birth,  31 
Paralysis,  infantile,  29 
obstetric,  55 
spastic,  31.     See  also  Birth 

palsy. 

Volkmann's  ischemic,  58 
Pelvis,  deformities  of,  62 
Pigeon  breast,  47 

causes,  47 
Pigeon-toe,  68 

walk  in  equinovarus,  15 
Plaster-of-Paris  casts  for  sco- 

liosis,  53 

for  tuberculosis  of  spine, 
40 


Plaster-of-Paris  casts  for  weak 

feet,   84 
in  bone  tuberculosis,  39, 

40 
in  congenital   dislocation 

of  hip,  19 
in  talipes,  16 
in  torticollis,  21,   22 
Poker-back,  54 
Policeman's  heel,  69 
Poliomyelitis,     anterior,      29. 
See  also  Infantile  paralysis 
Posture,  faulty,  scoliosis  from, 

50 

Pott's  disease,  brace  for,  42 
characteristic  attitude  in, 

33—37 

deformity  in,  33—37 
kyphosis  in,  36,  48 
muscle  spasm  in,  35 
pain  in,  34 
plaster-of-Paris  casts  for, 

40 

symptoms,   34 
tenderness    in,    35 
Prepatellar  bursitis,  6G 
Puberty,  scoliosis  at,  50 

RACIITTIC  rosary,  26,  46 

wry-neck,  44 

Rachitis,  24.  See  also  Rickets 
Rapid  growth,  scoliosis  from, 

50 

Regional  deformities,  44,  62 
Resistant  powers  of  feet,  78 
Rest  in  bone  tuberculosis,  39 

in  scoliosis,  53 


94 


INDEX 


Rheumatism,  wry-neck  from, 

44 
Rheumatoid  arthritis,  42 

causes,   42 

deformity   in,   43 

fever  in,  43 

from  tonsillitis,  42 

from  neglected   teeth,   42 

surgical  treatment,  43 

sweating  in,  43 

swelling  of  joints  in,  43 

symptoms,  42 

treatment,   43 

Ribs,   beaded,   in  rickets,   26 
Rib,  cervical,  44,  45 
Rickets,  24 

abnormal   growth   of  bones 
in,  25 

softness  of  bones  in,  25 
anterior  fontanelle  in,  26 
appearance  of  abdomen  in, 

26 

beaded  ribs  in,  26 
bow-legs  in,  26,  28 
causes,  24 

delayed  dentition  in,  27 
enlargement  of  abdomen  in, 
25 

of  liver  in,  26 
epiphyses  in,  26 
forehead  in,  26 
from  improper  food,  24,  25 
kyphosis  in,  27 
lordosis  in,  25,  26 
postural    deformity    in,    27, 

28. 

prevalence  among  poor,  24 
prognosis  in,  28 


Rickets,    proper    feeding    for, 
28 

retarded  development  in,  27 
shape  of  forehead  in,  26 
spinal  deformity  in,  27 
sweating  of  head  in,  25 
symptoms  of,  25 
treatment,  28 
wry-neck  from,  44 

Rickety  rosary,  26,  46 

Round  shoulders,  48.    See  also 
Kyphosis 

Running  sores  in  bone  tuber- 
culosis, 38 

SACRO-ILIAC  joints,   strain  of, 

62 

symptoms,  63 
treatment,  63 
Savages,  foot  troubles  among, 

76 
Scoliosis,  50 

advanced  stags,  52 

at  puberty,  50 

causes,  50 

conditions  associated  with, 

53 

course  of,  51,  52 
early  stages,  51 
effects  of,  on  general  health, 

51 

fresh  air  in,  53 
from  faulty  posture,  50 
from  rapid  growth,  50 
importance  of  early  recog- 
nition of,  53 

muscular  exercises  in,  53 
plaster-of-Paris  casts  in,  53 


INDEX 


95 


Scoliosis,   pressure   on   spinal 

nerve  trunks  in,  52 
prevalence   in   girls,   50 
rest   in,    53 
S-shaped  curve  of  spine  in. 

51 

structural  deformity  in,  52 
symptoms,   50 
tonics  in,  53 
treatment,  53 
Senile  osteo-arthritis,  41 
Shoes,  faulty,  77,  82 
examples  of,  78 
hallux  valgus  from,  82 
modern,  foot  troubles  from, 

77 
proper,  for  weak  feet,  83 

for  young,  81 

Shoulder,    congenital    disloca- 
tion of,  54 
deformities  of,  54 
Shoulders,  round,  48.  See  also 

Kyphosis 
Sinus,    discharging,    in    bone 

tuberculosis,  38 
Spasm  in  birth  palsy,  31 
Spastic    paralysis,     31.       See 

also  Birth  palsy 
Spinal    deformity    in    rickets, 

27 
nerve-trunks,    pressure    on, 

in  scoliosis,  52 
tuberculosis,   34.     See   also 

Pott's  disease 

Spine,  bending  forward  of,  49 
deformities  of,  47 
lateral     curvature     of,     50 
See  also  Scoliosis 


Spine,   S-shaped   curve  of,  in 

scoliosis,  51 
Spondylitis  deformans,  53 

characteristic  attitude  in, 

53 

poker-back  in,  54 
rounded  kyphosis   in,   54 
treatment,  54 
Sternocleidomastoid      muscle, 

contraction  of,  21 
Stiff  neck,  44.     See  also  Wry- 
neck,   acquired 
Strain,  effects  of,  on  feet,  80 

of  sacro-iliac  joints,  62 
Subdeltoid  bursitis,  56,  57 
Supernumerary      bones,      de- 
formity from,  23 
Surgery,  orthopedic,  definition 

of,  11 

Sweating    in    rheumatoid    ar- 
thritis, 43 
in  rickets,  26 

TALIPES,    adhesive    strapping 

in,  16 

calcaneus,  12,  13 
combinations  of,  14 
congenital,  14 
danger  of  relapse  in,  16 
early  recognition  of,  16 
early  treatment  for,  16 
effects   of,   on    development 

of  feet,  15 
equinovarus,   14 

pigeon-toe  walk  in,  15 

symptoms,  15 
equinus,  12,  13 
from  weak  feet,  81 


96 


INDEX 


Talipes,  hereditary,   12 

importance      of      thorough 

treatment  in,  15,   16 
manipulative  correction  of, 

16 

plaster-of -Paris  cast  for,  10 
recognition    of,    in    infants, 

15 

symptoms,  15 
treatment,  15 
of  mild  cases,  16 
of  neglected  cases,  17 
of  resistant  cases,  16 
of  severe  cases,  16 
valgus,  13,  14 
varieties  of,  12,  13 
varus,  12,  13 
Teeth,   ulcerated,   rheumatoid 

arthritis  from,  42 
Tennis  elbow,  57 
Toe,      congenital      malforma- 
tion of,  70 
deformities  of,  70 
hammer,  73 
Morton's,   75 
trigger,  74 

Tonics  in  scoliosis,   53 
Tonsillitis,      rheumatoid      ar- 
thritis from,  42 
Torticollis,  21 
after-treatment  for,  22 
cause  of,  21 
correctve    manipulation    of, 

21 

overcorrection  for,  21 
Traumatisni,    wry-neck   from, 

44 
Trigger  finger,  61 


Trigger  finger,  cause,  61 

treatment,  61 
Trigger  toe,  74 
Tubercle  bacillus,  32 
Tuberculosis  of  bones,  32.  See 

also  Pott's  disease 
of  cervical  spine,  33 
of  dorsal  spine,  34 
of  hip,  35 

characteristic  attitude  in, 

37,  38 

deformity  in,  36 
muscle  spasm  in,  36 
pain  in,  35 
symptoms,  35 
tenderness  in,  35 
of  joints,  37 

of  knee,    characteristic   ap- 
pearance, 39 
contractions  in,  37 
deformity  swelling  in,  37 
muscle  spasm  in,  37 
pain  in,  37 
tenderness  in,  37 
of  spine,  34.    See  also  Pott's 
disease 

VOLKMANN'S  ischemic  paraly- 
sis, 58 
causes,  58 
treatment,  59 

WALKING,    improper    position 

of  feet  in,  84 
proper   position  of  feet   in, 

84 
Weak  feet,  76,  80 

advanced,  80 


INDEX 


97 


Weak  feet,  arch  support  for, 

84 

associated  with  other  con- 
ditions,   treatment,    84 
club-foot  from,  81 
conditions  associated 

with,  79 

deformity  in,  81,  85 
examination  of,  79 
hallux  valgus  from,  80 
hammer  toe  from,  80 
how  to  rest,  83 
Morton's  toe  from,  80 
operative    treatment,    85 
orthopedic  treatment,  83 
pain  in,   79 
plaster-of-Paris    casts    in, 

84 
prevention  of,  83 

in  young,  81 
prognosis,  85 
proper  shoes  for,  83 

7 


Weak  feet,  severest  type,  85 
special  exercises  for,   83 
symptoms   of,    79 
treatment,  83 
Weeping  sinew,  59 
Whitman  frame,  39,  40 
Wrist,  deformities  of,  57 

ganglion  of,  59 
Wry-neck,   acquired,   44 
causes,  44 
from    bone    tuberculosis 

44 

from  catching  cold,  44 
from  rheumatism,  41 
from  rickets,  44 
from  traumatism,  44 
hot  compresses  for,  44 
treatment,   44 
congenital,    21.      See    also 

Torticollis 
rachitic,  44 


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Death,  Bandaging,  Care  of  Infants,  etc. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  M.  A. 
STONEY.  Revised  by  FREDERIC  R.  GRIFFITH,  M.  D.,  New  York. 
i2mo  volume  of  311  pages,  fully  illustrated.  Cloth,  $1.50  net. 


JUST  OUT 
2d  EDITION 


Goodnow's  First- Year  Nursing 

Miss  Goodnow's  work  deals  entirely  with  the  practical  side  of 
first-year  nursing  work.  It  is  the  application  of  text-book 
knowledge.  It  tells  the  nurse  how  to  do  those  things  she  is  called 
upon  to  do  in  her  first  year  in  the  training  school — the  actual 
ward  work. 

First-Year  Nursing.  By  MINNIE  GOODNOW,  R.  N.f  formerly  Super- 
intendent of  the  Women's  Hospital,  Denver.  izmoof  354  pages, 
illustrated.  Cloth,  $1.50  net. 


Aikens'  Hospital  Management 

This  is  just  the  work  for  hospital  superintendents,  training- 
school  principals,  physicians,  and  all  who  are  actively  inter- 
ested in  hospital  administration.  The  Medical  Record  says: 
"Tells  in  concise  form  exactly  what  a  hospital  should  do 
and  how  it  should  be  run,  from  the  scrubwoman  up  to  its 
financing." 

Hospital  Management.  Arranged  and  edited  by  CHARLOTTE  A. 
AIKENS,  formerly  Director  o£  Sibley  Memorial  Hospital,  Washing- 
ton, D.  C.  I2D1O  of  488  pages,  illustrated.  Cloth,  $3.00  net 


JUST  READY 
NEW  (3d)  EDITION 


Aikens'  Primary  Studies 

Trained  Nurse  and  Hospital  Review  says:  "  It  is  safe  to  say 
that  any  pupil  who  has  mastered  even  the  major  portion  of 
this  work  would  be  one  of  the  best  prepared  first  year  pupils 
who  ever  stood  for  examination." 

Primary  Studies  for  Nurses.  By  CHARLOTTE  A.  AlKENS,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  i2mo  of 
47i  pages,  illustrated.  Cloth,  $1.75  net 

Aikens'  Training-School  Methods  and 
the  Head  Nurse 

This  work  not  only  tells  how  to  teach,  but  also  what  should 
be  taught  the  nurse  and  hoiv  much.  The  Medical  Record  says: 
*'  This  book  is  original,  breezy  and  healthy." 

Hospital  Training-School  Methods  and  the  Head  Nurse.  By  CHAR- 
LOTTE A.  AIKENS,  formerly  Director  of  Sibley  Memorial  Hospital, 
Washington,  D.  C.  i2mo  of  267  pages.  Cloth,  $1.50  net 

Aikens'    Clinical    Studies       NEW  (2d)  EDITIOW 

This  work  for  second  and  third  year  students  is  written  on  the 
same  lines  as  the  author's  successful  work  for  primary  stu- 
dents. Dietetic  and  Hygienic  Gazette  says  there  ' '  is  a  large 
amount  of  practical  information  in  this  book." 

Clinical  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  i2mo  of 
56g  pages,  illustrated  Cloth,  $2.00  net 


Bohm  &  Painter's  Massage 

The  methods  described  are  those  employed  in  Hoffa's  Clinic 
— methods  that  give  results.  Every  step  is  illustrated,  showing 
you  the  exact  direction  of  the  strokings.  The  pictures  are 
large.  You  get  the  technic  used  in  Professor  Hoffa's  Clinic. 

Octavo  of  91  pages,  with  97  illustrations.  By  MAX  BOHM,  M.  D., 
Berlin,  Germany.  Edited  by  CHARLES  F.  PAINTER,  M.  D.,  Professor 
or  Orthopedic  Surgery,  Tufts  College  Medical  School,  Boston. 

Cloth,  $1.75  net 


SECOND 
EDITION 


Grafstrom's  Mechano-therapy 

Dr.  Grafstrom  gives  you  here  the  Swedish  system  of  mechan- 
otherapy.  You  are  given  the  effects  of  certain  movements, 
gymnastic  postures,  medical  gymnastics,  general  massage 
treatment,  massage  for  the  various  conditions.  The  illustra- 
tions are  full-page  line  drawings. 

Mechanotherapy  (Massage  and  Medical  Gymnastics).  By  AXEL  V. 
GRAFSTROM,  B.  Sc.,  M.  D.,  Attending  Physician  Gustavus  Adolphus 
Orphanage,  Jamestown,  New  York.  i6mo  of  200  pages. 

Cloth,  $1.25  net 

Friedenwald  and  Ruhrah's  Dietetics  for 

lN  UFSeS  NEW  (3d)   EDITION 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse, 
both  in  training  school  and  after  graduation.  American  Jour- 
nal of  Nursing  says  it  "is  exactly  the  book  for  which  nurses 
and  others  have  long  and  vainly  sought." 

Dietetics  for  Nurses.  By  JULIUS  FRIEDENWALD,  M.  D.,  Professor  of 
Diseases  of  the  Stomach,  and  JOHN  RUHRAH,  M.D.,  Professor  of 
Diseases  of  Children,  College  of  Physicians  and  Surgeons,  Baltimore. 
12010  volume  of  431  pages.  Cloth,  $1.50  net 


Friedenwald  &  Ruhrah  on  Diet 

This  work  is  a  fuller  treatment  of  the  subject  of  diet,  pre- 
sented along  the  same  lines  as  the  smaller  work.  Everything 
concerning  diets,  their  preparation  and  use,  coloric  values, 
rectal  feeding,  etc.,  is  here  given  in  the  light  of  the  most  re- 
cent researches. 

Diet  in  Health  and  Disease.    By  JULIUS   FRIEDENWALD,   M.D.,  and 
JOHN  RUHRAH,  M.D.'   Octavo  volume  of  857  pages.     Cloth,  $4.00  net 


Pyle's  Personal  Hygiene        NEw 

Dr.  Pyle's  work  discusses  the  care  of  the  teeth,  skin,  com- 
plexion and  hair,  bathing,  clothing,  mouth  breathing,  catch- 
ing cold;  singing,  care  of  the  'eyes,  school  hygiene,  body 
posture,  ventilation,  heating,  water  supply,  house-cleaning, 
home  gymnastics,  first-aid  measures,  etc. 

A  Manual  of  Personal  Hygiene.  Edited  by  WALTER  L.  PYLE,  M.  D., 
Wills  Eye  Hospital,  Philadelphia.  i2mo,  54?  pages  of  illus.  $1.50  net 

Galbraith's  Personal    Hygiene  and   Physical 

Training   for   Women  ILLUSTRATED 

Dr.  Galbraith's  book  tells  you  how  to  train  the  physical  pow- 
ers to  their  highest  degree  of  efficiency  by  means  of  fresh  air, 
tonic  baths,  proper  food  and  clothing,  gymnastic  and  outdoor 
exercise.  There  are  chapters  on  the  skin,  hair,  development 
of  the  form,  carriage,  dancing,  walking,  running,  swimming, 
rowing,  and  other  outdoor  sports. 

Personal  Hygiene  and  Physical  Training  for  Women.  By  ANNA  M. 
GALBRAITH,  M.D.,  Fellow  New  York  Academy  of  Medicine.  lamo  of 
371  pages,  illustrated.  Cloth,  $2.00  net 

Galbraith's  Four  Epochs  of  Woman's  Life 

This  book  covers  each  epoch  fully,  in  a  clean,  instructive  way, 
taking  up  puberty,  menstruation,  marriage,  sexual  instinct, 
sterility,  pregnancy,  confinement,  nursing,  the  menopause. 

The  Four  Epochs  of  Woman's  Life.  By  ANNA  M.  GALBRAITH,  M.  D. 
With  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.  D.,  University  of 
Pennsylvania,  izmo  of  247  pages.  Cloth,  $1.50  net 


JUST  OUT 
NEW  (6th)  EDITION 


Griffith's  Care  of  the  Baby 

Here  is  a  book  that  tells  in  simple,  straightforward  language 
exactly  how  to  care  for  the  baby  in  health  and  disease ;  how 
to  keep  it  well  and  strong;  and  should  it  fall  sick,  how  to 
carry  out  the  physician's  instructions  and  nurse  it  back  to 
health  again. 

The  Care  of  the  Baby.     By  J.  P.  CROZER  GRIFFITH,  M.D.,  Univers- 
ity of  Pennsylvania.     i2mo  of  458  pages,  illustrated.     Cloth,  $1.50  net 


Hoxie  &  Laptad's  Medicine  for  Nurses 

Medicine  for  Nurses  and  Housemothers.  By  GEORGE 
•  HOWARD  HOXIE,  M.  D.,  University  of  Kansas;  and 

PEARI,  L.  LAPTAD.         12mo  of  351  pages,  illustrated. 

Cloth,  $1.50  net.  New  (2d)  Edition. 

This  book  gives  you.  information  that  will  help  you  to  carry  out  the 
directions  of  the  physician  and  care  for  the  sick  in  emergencies.  It 
teaches  you  how  to  recognize  any  signs  and  changes  that  may  occur  be- 
tween visits  of  the  physician,  and,  if  necessary,  to  meet  conditions  until 
the  physician's  arrival. 

Boyd's  State  Registration  for  Nurses 

State  Registration  for  Nurses.  By  LOUIE  CROFT  BOYD, 
R.  N.,  Graduate  Colorado  Training  School  for  Nurses. 
Octovo  of  149  pages.  Cloth,  $1.25  net.  New  (2d)  Edition. 

Morrow's  Immediate  Care  of  Injured 

Immediate  Care  of  the  Injured.    By  ALBERT  S.  MOR- 
ROW, M.  D.,  New  York  City  Home  for  Aged  and  In- 
firm.    Octavo  of  354  pages,  with  242  illustrations. 
Cloth,  $2.50  net.  New  (2d)  Edition. 

deNancrede's  Anatomy  NEW  (7«h)  EDITION 

Essentials  of  Anatomy.  By  CHARLES  B.  G.  DENAN- 
CREDE,  M.  D.,  University  of  Michigan.  12mo  of  400 
pages,  180  illustrations.  Cloth,  $1.00  net. 


Morris'  Materia  Medica 


NEW  «?»«  EDITION 


Essentials  of  Materia  Medica,  Therapeutics,  and  Pre- 
scription Writing.  By  HENRY  MORRIS,  M.  D.  Re- 
vised by  W.  A.  BASTKDO,  M,  D.,  Columbia  University, 
New  York.  12mo  of  300  pages,  illustrated. 

Cloth,  $1.00  uet. 


Register's  Fever  Nursing 


A  Text  Book  on  Practical  Fever  Nursing.  By  EDWARD 
C.  REGISTER,  M.  D.,  North  Carolina  Medical  College. 
Octavo  of  35G  pages,  illustrated.  Cloth,  $2.50  net. 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 


This  book  is  due  on  the  last  date  stampeH  below,  or 

on  the  date  to  which  renewed. 
Renewed  books  are  subject  to  immediate  recall. 


MAR  14  (964 


\  J  U  k 


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